bluuebunny/crossref_metadata_2025 huggingface dataset:
P157: Pain management post-emergency department discharge: how are analgesics being consumed by patients with ongoing pain?
Authors: Weicker S. A. , Tuyp B. J. , Wormsbecker S.
Published: May 2018

Introduction: Pain management is a cornerstone of emergency department (ED) practice, yet ongoing pain after ED discharge and return visits for inadequate analgesia are common. Over-the-counter (OTC) acetaminophen and nonsteroidal anti-inflammatory drugs are widely accepted first line agents for mild to moderate pain. Previous research has not investigated how patients actually consume such agents after discharge, and if they consume them synergistically and at sufficient doses for optimal analgesia. We sought to determine the proportion of patients in ongoing pain post-discharge that were utilizing analgesics as well as the type and dose of agent(s) used. Methods: Adults presenting to our ED with an acutely painful musculoskeletal complaint during research assistant hours were eligible for enrollment. After excluding non-English speakers as well as admitted, pregnant/breastfeeding, and chronic pain patients, consenting subjects completed in-person questionnaires during their ED stay and a follow-up telephone interview 2-3 days later. Results: 158 individuals were approached during the study period, of which 99 enrolled. 78 completed follow-up. At follow-up, 71 (91%) individuals experienced ongoing pain with a median score of 5 (interquartile range (IQR) 3-6) on an 11-point scale. 48 (67%) of patients still in pain consumed analgesics in the preceding 24 hours. The most commonly used agents were acetaminophen by 18 individuals (38% of analgesic users), ibuprofen by 16 (33%), and naproxen by 9 (19%). 29 respondents (60% of analgesic users) were using solely oral OTC analgesics. Only 15 (31% of analgesic users) used multiple agents concurrently, and 11 (23%) used prescription opioids. Acetaminophen was used at a median daily dose of 1500mg (IQR 1000-2000mg), much lower than that recommended for maximal analgesia (4000mg). Ibuprofen daily doses (1200mg, IQR 800-1300mg) were slightly lower than typical recommended doses (1600mg, 400mg every 6 hours). Conclusion: Only two-thirds of patients with ongoing pain at 2-3 days post-ED discharge were consuming analgesics, most commonly acetaminophen and ibuprofen. Of patients using analgesics, less than one-third used multiple agents. OTC medications are not used by most patients at doses for maximal analgesia. It may be possible to reduce pain burden and repeat-visits in discharged ED patients by optimizing the use of OTC analgesics.
P158: Sensitivity analysis of CTAS temperature modifier in the emergency department
Authors: Weldon M. AJ. , Bullard M. , Gauri A. , Golberg G. , Priya J.
Published: May 2018

Introduction: The importance of early recognition and treatment of Sepsis has been emphasized over the last several years. In an attempt to better prioritize these patients, the Canadian Triage and Acuity Scale (CTAS) revised the adult temperature modifier after 2008 to define fever as 38.0C or higher and apply SIRS criteria, appearance and immunocompromise to assign a CTAS level of 2, 3, or 4. Prior to 2008, the fever threshold was defined as 38.5C and SIRS criteria were not included. This study looks to see if these changes increased the sensitivity of the temperature modifier. Methods: This study is a retrospective cohort analysis of patients presenting with a temperature of <36.0C or >38.0C to six Edmonton-area EDs in calendar years 2008 (n=26181) and 2012 (n=51622). Outcomes of interest included the temperature modifier predicted score and the actual assigned CTAS score. Data was extracted from the HASS/iSoft EDIS database including: presenting complaint, vital signs, CTAS score, and applied CTAS modifier to generate a before and after comparison of the actual and theoretical impact of temperature modifier revisions on the CTAS score, for both time periods. Results: Applying the pre-2008 temperature modifier to the 2008 patient cohort assigned 11.5% to CTAS 2, 39.8% to CTAS 3, and 33.3% to CTAS 4. Applying the post-2008 revised temperature modifier assigned 22.2% CTAS 2, 41.9% CTAS 3, and 27.6% CTAS 4. Carrying out the same analysis on the 2012 patients pre- results were 12.4% CTAS 2, 46.4% CTAS 3, 30.2% CTAS 4; and the post results were 21% CTAS 2, 47.7% CTAS 3, and 25% CTAS 4. Differences between pre- and post-results were statistically significant (p<0.0001) in both years. The actual triage scores in 2012 were 18.7% CTAS 2 indicating the temperature modifier was not always correctly applied and 50.6% CTAS 3 as other modifiers were sometimes applied. Conclusion: There was a significant increase in sensitivity following the post 2008 revisions to the CTAS temperature modifier when applied to two large ED patient cohorts. The differences between theoretical and actual CTAS scores was less dramatic as nurses were able to apply other first order or special modifiers to assign an appropriate score. Further analysis will be carried out to determine the impact of the temperature modifier revisions on time to antibiotic and admission rates.
P161: Emergency department visits for hyperglycemia in emerging adults with diabetes: a health records review
Authors: Yan J. W. , Hamelin A. L. , Gushulak K. M. , Van Aarsen K. , Columbus M. , Stiell I. G.
Published: May 2018

Introduction: Patients with diabetes who are in emerging adulthood, defined as the life stage between 18-29 years, have unique challenges in managing their illness and are at risk of acute complications and loss to follow-up. The studys objective was to describe emergency department (ED) utilization for hyperglycemia in emerging adults with diabetes and to characterize 30-day outcomes including return visits and admission for hyperglycemia. Methods: This was a health records review of emerging adults presenting over a one-year period to four tertiary care EDs with a diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Research personnel collected data on patient characteristics, treatment, disposition, and determined if patients returned to the ED for hyperglycemia within 30 days. Descriptive statistics were used to summarize the data where appropriate. Results: There were 185 ED encounters for hyperglycemia, representing 116 unique emerging adult patients. Mean (SD) age was 23 (3.5) years and 50.9% were female. 80 (69.0%) had known type 1 diabetes, 11 (9.5%) had type 2, and 25 (21.5%) were newly diagnosed in the ED. Of 185 visits, 98 (53.0%) resulted in hospital admission. 56 (30.3%) returned to the ED for hyperglycemia within 30 days of their initial encounter, and 21 (11.4%) resulted in admission on this subsequent visit. Conclusion: We characterized ED utilization and 30-day outcomes of emerging adults with diabetes for hyperglycemia. Future research should focus on earlier identification of those at higher risk for recurrent ED visits or admission and the efficacy of interventions to prevent these adverse outcomes.
P163: Methanol poisoning by inhalation: a case series
Authors: Yaworski H. , Palatnick W. , Oleschuk C. , Ringland S. , Tenebein M.
Published: May 2018

Introduction: Methanol intoxication is a well-recognized toxicological emergency. While most cases of significant methanol poisoning occur via ingestion, there are reports in the literature of poisoning resulting from the inhalational route. We report a series of methanol intoxications secondary to inhalational abuse of a methanol containing lacquer thinner presenting to an inner city Emergency Department. Methods: A laboratory database was searched for methanol levels > 5 mmol/L. (16mg/dL). from January 1, 2010 to December 31, 2015. A chart review was completed to determine mode of poisoning, clinical presentation, treatment, and disposition. Results: We found 35 patients who made a total of 83 emergency department (ED) visits with a methanol level > 5mmol/L. (16mg/dL). The methanol levels ranged from 5.3-39.6 mmol/L. (16.96 -126.72 mg/dL) . 73% of poisonings were secondary to inhalation of a methanol-containing lacquer thinner. The median age of these patients was 43 years, and 49% were male. The majority of patients (96%) resided in the core area. The most frequent chief complaints were substance abuse/intoxication, gastrointestinal complaints, and chest pain. 18% of patients described visual symptoms. Treatments were fomepizole only (59%), fomepizole plus hemodialysis (26%), and hemodialysis alone (2%). 49% of patients were discharged from the ED, while 28% and 23% were admitted to an intensive care unit (ICU) and an internal medicine ward respectively. There were no cases of blindness. We describe a cohort of patients who developed methanol poisoning from inhalation of a methanol containing lacquer thinner that required treatment with fomepizole and hemodialysis. While almost 1/3 of these patients were admitted to ICU, 49% were discharged from the emergency department after a course of fomepizole. The etiology of this outbreak was found to be a change in the formulation of the lacquer thinner, substituting a higher concentration of methanol for toluene. The manufacturer and a number of local retail outlets were contacted. This resulted in the product being taken off the shelves by the retail outlets, and eventually, a change in the product formulation by the manufacturer, with a resultant decrease in the methanol content. After these actions, we have not seen any additional presentations of inhalational methanol intoxication. Conclusion: We report the largest case series to date of patients who presented with methanol intoxication, requiring fomepizole and/or hemodialysis, secondary to inhalation of a methanol containing lacquer thinner. Physician advocacy regarding the etiology of this outbreak resulted in collaboration with retail outlets and subsequent action by the manufacturer. This ended the outbreak.
P165: A Non-hierarchical mentorship model for professional development
Authors: Zaver F. , Paetow G. , Gottlieb M. , Chan T. M. , Lin M. , Gisondi M.
Published: May 2018

Introduction: Mentorship is an essential component of professional development and benefits include increased career satisfaction, scholarship, and efficiency of academic promotion. The Mastermind group, a collaborative, network-based model for mentorship has gained popularity in the business world. It comprises of a group of colleagues that provide mentorship and career advice for each other through regularly scheduled meetings. The group benefits from the combined intelligence and accumulated experience of the participants, who may be at different career stages. Methods: Academic Life in Emergency Medicine (ALiEM; www.aliem.com), a digital health professions education organization, conducted two Mastermind groups for 14 team members in 2017. The groups included all levels of academic rank from full professor to instructors, and represented 14 different medical schools in North America. Each Mastermind group completed a self-assessment summarizing their professional strengths and weaknesses, two homework assignments, and two 90-minute videoconference meetings, using a structured, moderator-facilitated format. Meetings were conducted on Google Hangouts on Air© (Google Inc.). In the initial group meeting, participants discussed their self-assessments, current projects, and career challenges. The second meeting allowed discussion of suggested professional development resources for each participant, actionable next steps, and an accountability timeline for each participant. The free, cloud-based platforms and voluntary basis for the Mastermind groups resulted in a zero-cost innovation. Results: In a post-intervention survey, the 14 participants rated the experience as 9.4/10 (response rate 100%) using a Likert scale. In a quasi-experimental analysis participants cited the need for career advice or assistance with a project as their reason for participating. Participants received specific resource recommendations during the sessions, including books, training courses, or conferences. Contacts outside the group for additional mentorship were made possible given the breadth of networks among the participants. All participants had at least one identifiable next step with accountability to the group. Overall, the participants described a synergy of energy, commitment to one anothers longitudinal success, and benefit from the diverse range of talent and expertise in the group. Many of the members discussed plans to replicate this mentorship model at their own institutions. Conclusion: Our experiences suggest that the Mastermind conceptual framework is an easily replicated, feasible, zero-cost, and effective model for professional development. Though the model was originally proposed as a method for in-person discussions, we report a more modern, online experience for professional development in our diverse, globally-distributed team.
P166: The chief resident incubator - a virtual community of practice
Authors: Zaver F. , Gisondi M. , Chou A. , Sheehy M. , Lin M.
Published: May 2018

Introduction: The Emergency Medicine Chief Resident Incubator is a year-long curriculum for chief residents that aims to provide participants with a virtual community of practice, formal administrative training, mentorship, and opportunities for scholarship. Methods: The Chief Resident Incubator was designed by Academic Life in Emergency Medicine (ALiEM; www.aliem.com) a digital health professions education organization in 2015, following a needs assessment in emergency medicine. A 12-month curriculum was created using constructivist social learning theory, with specific learning objectives that reflected 11 key administrative or professional development domains deemed important to chief residents. The topics covered included interviewing skills, contract negotiations, leadership, coaching, branding, conflict resolution, and ended with a focus on wellness and career longevity. A Core Leadership Team and Virtual Mentors were recruited to lead each annual iteration of the curriculum. The Incubator was implemented as a virtual community of practice using Slack©, a messaging and digital communication platform. Ancillary technology such as Google Hangout on Air© and Mailchimp© were used to facilitate learner engagement with the curriculum. Three in person networking events were hosted at three large emergency medicine and education conferences with special medical education guests. Outcomes include chief resident participation rates, Slack© activity, Google Hangout© web analytics, newsletter email engagement, and scholarship. We also incorporated a hidden curriculum throughout the year with multiple online publications, competitions for guest grand round presentations, and incorporation of digital technologies in medical education. Results: A total of 584 chief residents have participated over the first 3 years of the Chief Resident Incubator; this includes chief residents from over 212 residency programs across North America. Over 27,000 messages have been shared on Slack© (median 214 per week). A total of 32 Google Hangouts© have occurred over the course of the inaugural Incubator including faculty mentorship from Dr. Rob Rogers, Dr. Dara Kass and Dr. Amal Mattu. A monthly newsletter was distributed to the participants with an opening rate of 59%. Scholarship included 26 published academic blog posts, 2 open access In-Training exam prepbooks, a senior level online curriculum with 9 published modules and 3 book club reviews. Conclusion: The Chief Resident Incubator is a virtual community of practice that provides longitudinal training and mentorship for chief residents. This Incubator framework may be used to design similar professional development curricula across various health professions using an online digital platform.
PL01: Multicentre before-after implementation study of the Ottawa subarachnoid hemorrhage strategy
Authors: Perry J. J. , Sivilotti M. L.A. , Emond M. , Hohl C. M. , Lesiuk H. , Sutherland J. , Khan M. , Abdulaziz K. , Wells G. A. , Stiell I. G.
Published: May 2018

Introduction: The Ottawa SAH Rule was developed to identify patients at high-risk for subarachnoid hemorrhage (SAH) who require investigations and the 6-Hour CT Rule found that computed tomography (CT) was 100% sensitive for SAH 6 hours of headache onset. Together, they form the Ottawa SAH Strategy. Our objectives were to assess: 1) Safety of the Ottawa SAH Strategy and its 2) Impact on: a) CTs, b) LPs, c) ED length of stay, and d) CT angiography (CTA). Methods: We conducted a multicentre prospective before/after study at 6 tertiary-care EDs January 2010 to December 2016 (implementation July 2013). Consecutive alert, neurologically intact adults with a headache peaking within one hour were included. SAH was defined by subarachnoid blood on head CT (radiologists final report); xanthochromia in the cerebrospinal fluid (CSF); >1x106/L red blood cells in the final tube of CSF with an aneurysm on CTA. Results: We enrolled 3,669 patients, 1,743 before and 1,926 after implementation, including 185 with SAH. The investigation rate before implementation was 89.0% (range 82.9 to 95.6%) versus 88.4% (range 85.2 to 92.3%) after implementation. The proportion who had CT remained stable (88.0% versus 87.4%; p=0.60), while the proportion who had LP decreased from 38.9% to 25.9% (p<0.001), and the proportion investigated with CTA increased from 18.8% to 21.6% (p=0.036). The additional testing rate (i.e. LP or CTA) diminishedfrom 50.1% to 40.8% (p<0.001). The proportion admitted declined from 9.8% to 7.3% (p=0.008), while the mean length of ED stay was stable (6.2 +/− 4.0 to 6.4 +/− 4.1 hours; p=0.45). For the 1,201 patients with CT 6 hours, there was an absolute decrease in additional testing (i.e. LP or CTA) of 15.0% (46.6% versus 31.6%; p<0.001). The sensitivity of the Ottawa SAH Rule was 100% (95%CI: 98-100%), and the 6-Hour CT Rule was 95.3% (95%CI: 88.9-98.3) for SAH. Five patients with early CT had SAH with CT reported as normal: 2 unruptured aneuryms on CTA and presumed traumatic LP (determined by treating neurosurgeon); 1 missed by the radiologist on the initial interpretation; 1 dural vein fistula (i.e. non-aneuyrsmal); and 1 profoundly anemic (Hgb 63g/L). Conclusion: The Ottawa SAH Strategy is highly sensitive and can be used routinely when SAH is being considered in alert and neurologically intact headache patients. Its implementation was associated with a decrease in LPs and admissions to hospital.
LO01: Analysis of bystander CPR quality during out-of-hospital cardiac arrest using data derived from automated external defibrillators
Authors: Fernando S. M. , Vaillancourt C. , Morrow S. , Stiell I. G.
Published: May 2018

Introduction: Out-of-hospital cardiac arrest (OHCA) is associated with high mortality, and CPR quality is one of the few modifiable factors associated with improved outcomes. Particularly, bystander CPR has been shown to improve survival and neurological outcomes in OHCA. However, the quality of CPR performed by bystanders in OHCA is unknown. We evaluated bystander CPR quality during OHCA, utilizing data stored within Automated External Defibrillators (AEDs), and matched with cases enrolled in the Resuscitation Outcomes Consortium (ROC) database. Methods: This cohort study included adult OHCA cases from the Ottawa ROC site between 2011-2016, which were of presumed cardiac etiology, not witnessed by EMS, and where an AED was utilized by a bystander with > 1 minute of CPR process data available. AED data from Ottawa Paramedic Services was matched to each case identified by the ROC database. AED data was analyzed using manufacturer software to determine overall measures of bystander CPR quality, changes in bystander CPR quality over time, and bystander adherence to existing 2010 Resuscitation Guidelines. Results: 100 cases met all inclusion criteria. 75.0% of patients were male, with a mean age of 62.3 years. 58.0% of arrests occurred in the home setting, and 24.0% were witnessed arrests. Initial rhythm was ventricular fibrillation/ventricular tachycardia in 36.0% of cases. Overall survival rate was 42.0%, with a modified Rankin Score of 3.7 (95% CI: 2.9-4.5). Bystanders demonstrated high-quality CPR over the course of resuscitation, with a chest compression fraction (CCF) of 75.9% (73.6-78.1), a compression depth of 5.26 cm (5.03-5.49), and a compression rate of 111.2/min (107.7-114.7). Mean peri-shock pause was 26.8 seconds (24.6-29.1). Adherence rates to 2010 Resuscitation Guidelines for compression rate and depth were 66.0% (60.9-71.1) and 54.9% (48.6-61.3), respectively. CPR quality was lowest in the first minute of resuscitation, during which rhythm analysis took place (mean 40.5 sec). In cases involving a shockable rhythm, overall latency from initiation of AED to shock delivery was 59.2 sec (45.5-72.8). Conclusion: We found that bystanders perform high-quality CPR, with strong adherence rates to existing Resuscitation Guidelines. Our findings provide evidence of the quality of bystander CPR performed during OHCA.
LO04: Health effects of training laypeople to deliver emergency care in underserviced populations: preliminary results of a systematic review
Authors: Orkin A. , Curran J. , Ritchie S. , van de Velde S. , VanderBurgh D.
Published: May 2018

Introduction: The World Health Organization recommends emergency care training for laypeople in low-resource settings, but the effects of these programs on patient outcomes and community health have not been systematically reviewed. Our objective was to identify the individual and community health effects of educating laypeople to deliver emergency care in low-resource settings. Methods: We conducted a systematic review to address this question: in low-resource populations (P), does emergency care education for laypeople (I) confer any measurable effect on patient morbidity and mortality, or community capacity and resilience for emergency health conditions (O), in comparison with no training or other education(C)? We searched 12 electronic databases and grey literature for quantitative studies. We conducted duplicate and independent title and abstract screening, methodological and outcomes extraction, and study quality assessment using the Effective Public Health Practice Tool. We developed a narrative summary of findings. (PROSPERO: CRD42014009685) Results: We reviewed 16,017 abstracts and 372 full-text papers. 38 met inclusion criteria. Most topically relevant papers were excluded because they assessed educational outcomes. Cardiopulmonary resuscitation training (6 papers) improved cardiac arrest survival and enhanced capacity to respond to cardiac arrest in rural Norway, Denmark and commercial aircraft operations. A public education campaign in remote Denmark improved absolute cardiac arrest survival by 5.4% (95%CI 2-12). Lay trauma training (12 papers) reduced absolute injury mortality and improved community capacity in Iraq, Cambodia, Iran and Indigenous New Zealand communities. A trauma care program in Iraq and Cambodia reduced absolute mortality by 25% (95%CI 17.2-33). Education for mothers on paediatric fevers in Ethiopia was associated with 40% relative reductions in under-5 mortality (95%CI 29.2-50.6). Similar training improved access to care for paediatric malnutrition, malaria, pneumonia, and gastrointestinal disease in Nigeria, Kenya, Senegal, Burkina Faso, Mali, and India (13 papers). Overdose education and naloxone distribution was associated with reductions in opioid overdose deaths (3 papers), including in Massachusetts where high-uptake communities for overdose education had significantly lower overdose fatality rates than no-uptake communities (rate ratio 0.54, 95%CI 0.39-0.76). Community education improved measures of access to emergency care for remote Indigenous populations in Canada, Alaska and Nepal (3 papers) and adolescent mental health capacity in Australia (1 paper). Studies were of low or medium quality. Conclusion: In addition to established interventions for injury and cardiac arrest, emergency care training can improve community capacity in underserviced populations, and save lives in opioid overdose, paediatric infectious disease and malnutrition.
LO07: Developing a culture of quality across Ontario’s emergency departments: the return visit quality program
Authors: Chartier L. , Ostrow O. , Yuen I. , Davis B. , Hayes E. , Kutty S. , Fairclough L. , Ovens H.
Published: May 2018

Introduction: In 2016, the Emergency Department (ED) Return Visit Quality Program (RVQP) was developed to promote a culture of quality in Ontario EDs, by mandating large-volume EDs to audit charts of patients who had a return visit leading to hospital admission (RV). This program provides an opportunity to identify possible adverse events (AEs) and quality issues, which can then be addressed to improve patient care. Methods: The RVQP requires EDs to audit a set number of 72-hour RVs for potential AEs/quality issues, as well as all 7-day RVs for one of three key paired sentinel diagnoses (acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis). Submitted audits and their AEs/quality issues were analyzed by a team of emergency physicians with quality improvement (QI) expertise, and qualitative metrics were derived. Using the general inductive method, we conducted a qualitative analysis with Health Quality Ontario (HQO), and HQO completed an independent analysis of the submitted narrative reports. Our objective is to report on the qualitative and quantitative metrics of the program, and to explore emerging themes from the AEs/quality issues identified. Results: There were 36,304 72-hour RVs flagged, which represent 0.99% of all 3,672,708 ED visits in the province of Ontario for the 86 EDs participating in the first year of the program. Overall, 2,584 audits were conducted. For the audits involving all-cause 72-hour RVs, 571 (24%) of cases had AEs/quality issues identified. Of the 219 audits involving sentinel diagnoses, 107 (49%) audits identified AEs/quality issues. The qualitative analysis revealed 11 themes, which were classified into three groups : issues related to patient characteristics or actions (elder care, patient risk profile, left without being seen); issues related to actions or processes of the ED team (physician cognitive lapses, handover/communication, high risk medications, documentation, radiology, vital signs); and healthcare system issues (imaging/test availability, discharge planning). Over one hundred local QI projects were completed or planned as a result of the audits performed. Conclusion: The RVQP promotes a culture of quality by highlighting potential AEs and quality themes that can then be targeted to increase patient safety and quality of care in Ontario EDs. Numerous QI projects were undertaken in the first year of the program, and future efforts will monitor the completion and success of these. The program can be easily adapted in other jurisdictions.
LO11: Improving patient access, care and transportation by paramedics (IMPACT): a novel curriculum toward redefining paramedic services in Ontario
Authors: Taher A. Khaled , Lockwood J. , Spearen C. , Kachur J. , Pino G. , Kedzierski N. , Tavares W.
Published: May 2018

Introduction: A proportion of Emergency Department (ED) visits may be treated in out-of-hospital settings. The objective of this curriculum was to expand paramedic competencies to safely risk stratify patients and divert low risk, low acuity patients from EDs with and without physician oversight. Methods: We followed Kerns 6-step Curriculum Development Framework . (a) We identified a problem, and (b) completed a needs assessment by retrospectively reviewing the clinical pathways of 3000 patients were cared for and transported by paramedics and received care at an EDs. We used this data to identify competencies (e.g., diagnostics, interventions, reasoning needs) and targeted patient types that would result in the most significant advancements to paramedic services. These were translated to (c) goals and objectives. Results: Our (d) educational strategies involved a 14-week intensive patient-type and case-based curriculum. (e) Implementation involved 3 days/wk of clinical rotations supplemented with 2 days/wk of a mixed curriculum (i.e., fixed instruction using blended didactic small and large group sessions; flexible/individualized curriculum based on identified needs; formative assessments; self and peer-directed learning; simulations). (f) Assessment involved knowledge and application tests, clinical placement and simulation assessments; case development, assignments, and OSCE. Evaluation outcomes included student performance scores across 7-dimensions, clinical placement and student feedback. Thirteen Advanced Care Paramedics from York Region Paramedic Services completed the program. Challenges included provincial stakeholder consensus, and formally addressing clinical suspicion in a protocol based field within a limited time frame. Conclusion: A curriculum for expanded paramedic practice to risk stratify and divert targeted low risk patients from EDs resulted in new paramedic competencies and scope of practice. It received high evaluations from clinical staff and students. Successful candidates will undergo a 1-year study for validation and safety.
LO13: Eye care in the emergency department: what proportion of patients presenting to the emergency department with isolated eye related complaints could alternatively be seen by an optometrist?
Authors: Phillips K. , Thorpe L. , Innes G.
Published: May 2018

Introduction: Approximately 2-3 percent of emergency department (ED) visits are due to eye-related complaints, adding to the ED workload. Many of these could be seen instead by an optometrist who specializes in the examination, diagnosis and treatment of eye-related disorders. We sought to determine the proportion of ED patients with isolated eye-related complaints that could be managed by an optometrist. Methods: We performed an administrative database study and descriptive analysis of all patients presenting to Calgary EDs with eye-related complaints during a one-year period. We determined optometry eligibility by reviewing discharge diagnoses and assessing whether that condition was within the Alberta Association of Optometrys (AAO) defined scope of practice. Patients were considered ineligible if their condition was related to bites, stings, thermal burns, assault, MVA or operative complications; if they required hospitalization or referral to a non-eye specialist (e.g. neurology); if they had associated headache, dizziness, syncope, hypertension, neurologic abnormality (e.g. diplopia); if they had facial cellulitis, orbital infections, adverse drug effects, or if they underwent observation in the ED because of concerns about a cardiac or neurological condition. Results: In 2015, 7686 patients were seen in Calgarys 5 EDs with eye related complaints. Of these, 76.2% were optometry-eligible and 75% of optometry-eligible patients arrived during day or evening hours (0800-2100). The most common presenting complaints were visual disturbance (24.8%), redness (22.1%), and pain or photophobia (16.4%). Optometry-eligible patients waited an average of 110 min and had an ED LOS of 149 min. Conclusion: Approximately 3 in every 4 patients seen in the ED for eye related complaints could alternatively be seen by an optometrist. Further research is required to establish the feasibility of diversion to an optometrist from the ED for eye-related complaints.
LO14: In emergency department, do serum biomarkers are useful to screen independent frail seniors exposed to functional or mobility impairments after a minor injury?
Authors: Emond M. , Blouin M. , Sirois M. , Aubertin-Leheudre M. , Griffith L. , Nadeau L. , Daoust R. , Lee J.
Published: May 2018

Introduction: Frailty is a geriatric syndrome conferring a high risk of declining functional capacities. Some serum biomarkers were associated with frailty, but no study has investigated this possible association among community-dwelling seniors with minor injuries in the emergency department (ED). The aim was to determine if ED serum biomarker assay combined with frailty status improve the prediction of 3-months functional or mobility impairments in this population, beyond frailty status alone. Methods: This prospective sub-study of the CETI cohort includes 190 participants (age 65 years, ED consultation within 2 weeks of a minor injury, independent in daily activities 4 weeks prior to injury, and discharged home from EDs). Biomarkers were obtained from blood samples at baseline (ED visit). Normal vs. at risk physiological states were defined according to clinical threshold values. Also, the patients were screened for frailty at baseline) while their functional (OARS scale) and mobility characteristics were assessed at the ED visit and 3 months later. Patients were classified as robust or pre-frail/frail according of the CHSA-CFS and SOF scales. Simple generalized linear models with a binomial distribution and a log link function were used to explore the differences in functional and mobility outcomes at three months across sub-groups (RR). Results: When compared to robust ones, ED pre-frail/frail patients were less functional in their instrumental activities of day living (p=0.004), slower walkers (p=0.02), more frequent users of walking aids (p=0.03), more fearful of falling (p=0.006), went outside their home less often weekly (p=0.004) and had higher abnormal creatinine levels (p=0.02). We observed an overall 3-month functional decline in around 10% of patients combined with worsened mobility characteristics. We found that vitamin D [RR: 0.51 (0.07-3.9)], glucose (RR: 0.27 [(0.03-2.16)]) and creatinine (RR: [1.10 [(0.40-2.97]) modulate the prediction of 3-months mobility impairments. However, ED frailty status with CHSA-CFS and SOF scales clearly remained the stronger predictor of mobility impairments [vitamin DRR: 2.93 (1.12-7.65); glucoseRR: 2.36 (0.85-6.55); creatinine: RR2.06 (1.21-3.53)]. Conclusion: Since they do not improve the prediction of 3-months functional or mobility impairments associated with frailty status, ED biomarker assays are not useful in adequately screening for frailty among independent seniors with minor injuries.
LO15: Treatment of asymptomatic bacteriuria in elderly patients with delirium: a systematic review
Authors: Suleman A. , Krakovsky J. , Joo P.
Published: May 2018

Introduction: It is typical to look for UTI in delirious elderly patients, despite a high prevalence of asymptomatic bacteriuria (ASB) in this population. A common presentation of infection is delirium, which often has a non-specific and multifactorial etiology. Therefore, when bacteriuria is present with delirium in the absence of urinary symptoms, physicians prescribe antibiotics for the suspected UTI-induced delirium. We set to determine whether antibiotic treatment in the elderly presenting with delirium in the presence of ASB resulted in resolution of delirium. Methods: Literature searches were performed in MEDLINE, EMBASE, CINAHL and Cochrane Library. Abstracts were independently reviewed by two authors for decision to include for full-text review. Inclusion criteria included female gender, >65 years of age, presenting in an acute care setting with delirium and ASB. The primary outcome was resolution of delirium. The secondary outcomes were mortality, frequency of side effects from antibiotics, length of hospital stay and readmission for delirium. Results: 930 abstracts published from 1946-2017 were screened, and 42 were included for full text review. No studies were eligible for inclusion in the systematic review, as none addressed the primary outcome. One study addressed the outcomes of poor functional recovery after delirium and the rate of improvement of delirium symptoms after presentation of delirium with ASB. Conclusion: Even though current guidelines recommend against treatment of ASB, no guideline states whether ASB should be treated in elderly patients with delirium. Little evidence exists to elucidate whether treating delirious patients with ASB results in improvement in outcomes. Future studies should focus on demonstrating the relationship between resolution of delirium with antibiotic treatment. This will clarify whether delirium is a true symptom of ASB and whether treatment results in faster resolution of delirium.
LO18: Access to take home naloxone in the Royal Alexandra Hospitals emergency department for patients at risk of an opioid overdose
Authors: Dabbs D. W. , Dong K. , Lavergne K. , Brooks H. , Hyshka E.
Published: May 2018

Introduction: Take Home Naloxone (THN) programs prevent death from opioid poisoning by training laypersons to recognize an overdose and administer naloxone. Dispensing THN through the emergency department (ED) is particularly critical because an ED visit for opioid poisoning strongly predicts future mortality. Many EDs have implemented THN programs, yet almost no literature examines the reach of such initiatives. To address this gap, we conducted a chart review of all patients presenting for opioid poisoning to an urban tertiary hospital, with a large ED-based THN program. This exploratory study hypothesized that more than 50% of ED patients presenting for opioid poisoning would be offered a THN kit. Methods: Data on demographics, clinical characteristics, and THN kit dispensing were extracted and analyzed from the charts of all ED patients presenting with a primary diagnosis of opioid poisoning between April 1 2016 and April 30 2017. Logistic regression analyzed predictors of being offered a THN kit. Results: A total of 347 ED visits for 301 unique patients occurred during the study period. The mean age ± SD of patients was 38 ± 14 years, and 69% were male. In 49% of ED visits, a THN kit was offered; 73% of these episodes had a THN kit dispensation. Patients who were male (AOR=1.94; 95% CI 1.11 - 3.40), and reported that their overdose was unintentional (AOR=2.95; 95% CI 1.04 8.35) and caused by illegal opioids (AOR=4.73; 95% CI 2.63 8.52) were significantly more likely to be offered a THN kit. Conclusion: ED-based THN programs have the potential to reach significant proportions of patients at high risk of mortality. However, these programs may have differential reach within the target population. Further research is needed to examine barriers and facilitators to offering all eligible ED patients a THN kit.
LO20: Emergency department initiated drug therapy and patient compliance in acute renal colic
Authors: Watt A. , Brubacher J. , Cuthbertson L. , Stenstrom R. , Andruchow J. E. , Andolfatto G. , Weber B. , Innes G.
Published: May 2018

Introduction: NSAIDS offer more effective analgesia than opioids, require less rescue medication, and decrease the incidence of nausea and vomiting in renal colic patients. Alpha blockers and Opioids are also prescribed frequently, but doses used and treatment durations are not well described. Our objective was to investigate ED prescribing decisions and medication compliance by patients with acute renal colic. Methods: In this prospective two-city cohort study, we invited patients with a first ED visit for image-confirmed 2-10 mm ureteric stones to consent to a telephone survey 10 days after their ED visit. During follow-up interviews, patients were asked what drugs they were prescribed and how many doses they required. This study was REB approved. Results: A convenience sample of 224 patients, including 152 males (67.9%) and 72 females (median age= 52.4 years) completed 10-day surveys. NSAIDS were prescribed for 48.7%, tamsulosin for 65.2% and opioids for 81.7%. One-third received a tamsulosin-NSAID combination, 40% an opioid-NSAID combination and 28% a tamsulosin-NSAID-opioid combination. Of 109 patients prescribed an NSAID, only 70 (64.2%) took 1 dose/day; however an additional 28 who were not prescribed NSAIDs took 1 NSAID dose/day. Mean (sd) NSAID intake in the overall study group was 1.1 (1.5) doses/day from day 1-5 and 0.6 (1.1) doses/day on days 6-10, with 90%ile values of 3.0 and 2.0 doses/day. NSAID compliance was more common in patients who stated they received high quality discharge instructions (63.8% vs. 32.6%; RR=1.95; 95% CI 1.47-2.60). Mean opioid intake in the overall study group was 1.2 (1.7) doses/day from day 1-5 and 0.5 (1.3) doses/day on days 6-10, with 90%ile values of 4.0 and 2.0 doses/day. Among patients prescribed tamsulosin, the average was 4.0 days of compliance (sd=4.3), with a 90%ile value of 10 days. Conclusion: This study provides estimates for the amount of drug actually used by renal colic patients during the 10-days after their ED visit. Patients used fewer opioid doses than expected, and NSAID and tamsulosin compliance appears relatively poor. NSAID compliance was better in patients who perceived high quality discharge instructions. This study suggests there is room for improvement in medication prescribing and discharge instructions for ED patients with an acute episode of ureteral colic.
LO23: Reducing time to disposition for treat & release patients in the emergency department
Authors: Woolner V. , Ensafi S. , De Leon J. , George L. , Chartier L.
Published: May 2018

Introduction: Treat and Release (T&R) patients are seen and discharged home from the emergency department (ED), and asked to return within 12-72 hours for follow-up care (e.g., ultrasound, repeat blood work). Our two academic teaching hospitals see approximately 2,000 T&R patients per year. Handover of care for T&R patientsdone through charting only and therefore dependent on the charts adequacy and completenessis crucial to the safety and quality of care they receive. An 18-month retrospective chart audit at our sites identified quality gaps, including suboptimal documentation that ultimately impedes patient disposition. Our projects aim was to reduce the time-to-disposition (TTD; time spent by patients between provider initial assessment and discharge from the ED) by a third (from 70min) in 6-months time (March 2017), a target felt to be both meaningful and realistic by our stakeholder team. Methods: Our primary outcome measure was the TTD (in minutes). Our process measure was the quality of documentation, using a modified version of QNOTE, a validated tool used to assess the quality of health-care documentation. PDSA cycles included: 1) Involvement of stakeholders for the creation and refinement of an improved T&R handover tool to cue more specific documentation; 2) Education of health-care providers (HCPs) about T&R patients; 3) Replacement of the previous T&R handover tool with a newly designed and mandatory tool (i.e. a forcing function); 4) Refinement of the process for T&R patients and chart hold-over. Results: Run charts for both the median TTD and median modified QNOTE scores over time demonstrate a shift (i.e., run chart rule) associated with the second and third clustered PDSA cycles. After the first three clusters of PDSA cycles (i.e., before-and-after), mean TTD was reduced by 40% (70min to 42min, p=0.005). The quality of documentation (mean modified QNOTE scores) was also significantly improved (all results p<0.0001): patient assessment from 81% to 92%, plan of care from 58% to 85% and follow-up plan from 67% to 90%. Conclusion: We reduced the time-to-disposition for T&R patients by identifying gaps in the quality of documentation of their chart. Using iterative PDSA cycles, we improved their time-to-disposition through improved communication between health-care providers and a new T&R handover tool working as a forcing function. Other centers could use similar assessment methods and interventions to improve the care of T&R patients.
LO26: Reduction of CT scan use in emergency department patients with recurrent renal colic
Authors: Shelton D. M. , Berger F.
Published: May 2018

Introduction: CT scan is the most common imaging modality for suspected renal colic and is used for about 80% of presentations. Cumulative ionizing radiation exposure from repeat CT scans increases long-term cancer risk. Despite a 10-fold increase in CT use to detect kidney stones in the ED in just over a decade, there has been no increase in the proportion of kidney stones diagnosed, number of significant alternate diagnoses or admissions to hospital. Choosing Wisely recommends to avoid ordering CT of the abdomen/pelvis in otherwise healthy patients90% of patients < age 50 with a history of renal stones arriving in Sunnybrook ED with symptoms consistent with renal colic will be managed without a CT abdomen/pelvis. Methods: Emergency physicians were engaged in the process at various stages, including a brainstorming session to perform a root cause analysis. A Driver diagram was created to generate change ideas. Outcome Measure Number of CT scans ordered for target population (Results: Results to date indicate that there is a non-sustained decrease in the number of CT scans performed on ED patients < age 50 with recurrent renal colic. The STONE score was infrequently used, thus making it difficult to standardize CT ordering for presumed renal colic. Conclusion: As a result of this QI initiative, there is awareness amongst emergency physicians of a patient population that is over imaged with CT scan, often with no change in management. Introduction of a low dose CT scan order was the greatest gain from this QI initiative. In order to decrease CT utilization, physicians need to be shown the lack of benefit of CT use and a safe alternative diagnostic approach.
LO34: Does utilization of an intubation safety checklist reduce dangerous omissions during simulated resuscitation scenarios?
Authors: Forristal C. , Hayman K. , Smith N. , Mal S. , Columbus M. , Farooki N. , McLeod S. , Van Aarsen K. , Ouellette D.
Published: May 2018

Introduction: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.