bluuebunny/crossref_metadata_2025 huggingface dataset:
P034: Computed tomography rates for emergency department super-users
Authors: Savage D. , North R. , McKay G. , McMillan C. , Stonebridge R. , Piper B. , Jeffery A. , Ohle R. , VanderBurgh D.
Published: May 2020

Introduction: Most emergency departments (ED) in Canada have a population of high frequency users that present to the ED on a regular basis. These patients are well described in the literature and typically defined by a frequency of 8-10 visits/year. In Thunder Bay, Ontario we have a significant population of patients that present more often that we have termed “super-users”. These patients often are typically from a vulnerable population with multiple co-morbidities and a high mortality rate. Although their risk for poor health outcomes is well recognized, both the chronicity and complexity of their symptoms often contributes to diagnostic dilemmas. The decision to order a computed tomography (CT) scan can be a difficult balance between ruling out life threatening diagnoses and exposing the patient to excessive radiation. Our objective was to describe how often these super-users of the ED received a CT scan and what types of imaging were completed. Methods: The Thunder Bay Regional Health Sciences Centre is a geographically isolated hospital in Northwestern Ontario with the next closest hospital based CT scanner greater than 300 km away. Based on previous literature and our preliminary scoping of the super-user group, we have identified a minimum of 25 visits as the threshold. A retrospective chart review was conducted for the year 2017 using our electronic medical record. Patient demographic data was collected along with the type and number of CT scans into a standardized collection tool. Results: Our preliminary results showed that our total population of super-users was 75 patients with an average of 32 visits to the ED per year. A total of 76% of the patients had a CT scan completed at least once. On average these patients have a CT during 10% of their visits with head CT comprising 50% of the imaging and abdominal/pelvis imaging comprising another 45%. For 20% of these super-users, they had CTs on 20% of their visits. From this population, only 10% of the patients had surgery in 2017 while 7% of visits required admission to hospital. The most common diagnoses for these patient visits relate to mental health/addictions, gastrointestinal complaints and infection. Conclusion: This study has shown that a significant number of our super-user population are receiving multiple CTs. Our next step is collect data on individual radiation doses and calculate exposure risks. We hope to inform policy and decision-makers who are developing programs to treat the underlying cause of their high resource use.
P037: Adherence to the Canadian CT Head Rule in a Nova Scotian emergency and trauma centre
Authors: LeBlanc C. , Sampalli A. , Campbell S.
Published: May 2020

Introduction: Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada™ (CWC), aims to address unnecessary care and testing through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five interventions to question in the Emergency Department (ED). Zyluk (2015) determined the Canadian CT Head Rule (CCHR) as the most effective clinical decision rule in adults with minor head injuries. To better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center, in Halifax, Nova Scotia. Methods: Our mixed methods design included a literature review, retrospective chart audit, and a qualitative audit-feedback component with participating physicians. The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Analysis of qualitative data is included here, in parallel with in-depth to contextualize findings from the audit. Results: 302 charts of patients having presented to the surveyed site were retrospectively reviewed. Of the 37 cases where a CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusion: Our study reveals adherence to the CCHR in 87.8% of cases at this ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical for reducing unnecessary CTs. This work has been presented to the physician group to gain physician engagement and to elucidate enablers and barriers to guideline adherence. In light of the frequency of CT heads ordered EDs, even a small reduction would be impactful.
P050: The Northern Amazing and Awesome Model: Using positive deviance to impact patient care
Authors: Ohle R. , McIsaac S.
Published: May 2020

Introduction: Positive deviance recognizes that there are individuals and teams within our community of practice that succeed in spite of system constraints. Amazing and awesome rounds has been proposed as a forum to identify behaviours and processes that lead to exceptional results. The objective of this study was to determine the feasibility and acceptability of a structured amazing and awesome rounds model through an innovative educational intervention. Methods: The authors engaged a broad range of professional designations(physicians, surgeons, nurses, respiratory therapists, administrative staff) at a tertiary care institution. A&A rounds were open to all allied health professionals and administrative staff. The Northern A&A rounds model was developed, implemented, and then evaluated as a four-part intervention. This consisted of: 1) Allied health professional training on case selection and analysis, 2) Engaging inter professional members, 3) disseminating lessons learned, and 4) creating an administrative pathway for acting on issues identified through the A&A rounds. The measures of intervention feasibility included the proportion of sessions adherent to the new model and A&A rounds attendance. Post intervention surveys of presenters and attendees were used to determine intervention acceptability. A&A presentation content was reviewed to determine the most frequently adopted components of the model. Results: Nine out of 9(100%) of presented cases were adherent to the three components of the Northern A&A Model. A&A rounds were highest attended of all hospital wide grand rounds(N = 75 SD 2.4 P < 0.001). Nine case presentations were analyzed and 7 action items were identified for amplification across the hospital. Including 3 case reports published of a novel approach to a patient case,a rapid referral for trauma patients at risk for PTSD, AED placement in all community clinics and routine debrief after resuscitations. Presenters included a broad representation of hospital staff including surgeons, emergency physicians, radiologists, nurses, and administrators. Conclusion: The Northern A&A Model was a feasible intervention that was perceived to be effective by both presenters and attendees. The authors believe that this could be readily applied to any hospital seeking to enhance quality of care and patient safety.
P061: Barriers to distributing discharge materials in the emergency department
Authors: Maneshi A. , Gangatharan H. , Cormier M. , Gosselin S.
Published: May 2020

Introduction: An efficient discharging process provides an opportunity for the patient to receive information about their diagnosis, prognosis, treatments, follow-up plan and reasons to return. Even when given complete discharge instructions, studies demonstrate that patients have poor retention of the information due to misunderstandings, language barriers, or poor health literacy. This study sought to identify barriers encountered by healthcare workers in providing discharge handouts to emergency department patients. Methods: A bilingual online survey of fifteen questions was shared with Quebec ED staff physicians and residents at the annual conference, and by email correspondence through the Quebec Emergency Medicine Association (AMUQ - L'Association des médecins d'urgence du Québec). Results: There was a total of 126 responses (96 physicians and 30 residents), with a response rate of 22.7% (126/556) and a completion rate of 84.1%. 85.8% (n = 120) responded that they were aware of discharge instructions available in their ED. Most common discharge handouts were concussion/traumatic brain injury and laceration repair. 58.3% of respondents (n = 120) reported having handed out discharge instructions in the last week, 22.5% in the last month, 10.8% within the last 6 months and 5.8% had not given out discharge instructions in the last 6 months. Respondents indicated that the most common barriers to giving out discharge instructions were their difficulty to access and and the time required. 58% of respondents (n = 65) reported handing out discharge handouts less than 50% of the time for conditions that had a discharge handout available at their hospital. Participants reported they would be more likely to give out discharge instructions if they were easier to print and if there was an automatic prompt from the EMR associated with the diagnosis. When asked to rank based on importance (1 = not important to 10 = very important), the majority of respondents thought discharge instructions were very important for patient comprehension, return to ED instructions and managing expectations of the illness (Median 8, Likert scale 1-10, DI 0.29, n = 119). Conclusion: Despite physicians and residents working in the ED believing discharge instructions are important for patient care, handouts are seldom given to patients. The lack of easy availability such as documents automatically available with the prompt of an electronic medical record would likely increase their distribution.
P062: Characterizing pediatric emergency department discharge communication using PEDICSv2
Authors: MacCuspic K. , Breneol S. , Curran J.
Published: May 2020

Introduction: Discharge communication in the pediatric emergency department (ED) is an important aspect of successful transition home for patients and families. The content, process, and pattern of discharge communication in a pediatric ED encounter has yet to be comprehensively explored. The objective of this study was to identify and characterize elements and patterns of discharge communication occurring during pediatric ED visits between health care providers (HCPs) and families. Methods: We analyzed real time video observations (N = 53) of children (0-18) presenting to two Canadian pediatric EDs with fever or minor head injury. We used a revised version of an existing coding scheme, PEDICSv2, to code all encounters. PEDICSv2 includes 32 elements capturing discharge communication. Inter-rater reliability was established with a second coder. Descriptive statistics reflecting the rates of delivery of each communication content element was reported to assess repetition at four stages of the visit (introduction/planning, actions/interventions, diagnosis/home management plan and summary/conclusion). Communication content was analyzed to depict behaviors of individual HCPs and the total communication delivered to the patient and caregiver by the healthcare team. Results: Results show 55.6% of families were asked to repeat their main concern by multiple HCPs during their ED visit. However, only 14.8% of families had comprehension of delivered discharge information assessed by more than one HCP. When involved in care, physicians were the most likely HCP to perform a comprehension assessment. Most of the communication delivered by nursing staff were elements involved in the introduction/planning and action/intervention stages of the visit. Conclusion: Findings indicate that most repetition occurs while eliciting a main concern during the introduction and planning stage of a pediatric ED encounter. In contrast, communication elements focusing on understanding the home management plan are less likely to be repeated by multiple HCPs. Future work focusing on structuring team workflow to minimize repetition during the introduction and planning stage may allow for clearer discharge teaching and more frequent comprehension assessment.
P063: CCFP(EM) mentorship improvement study: highlighting the successes and challenges at one academic centre
Authors: Luo L. , Bhimani M.
Published: May 2020

Introduction: The Canadian College of Family Medicine Emergency Medicine Program (CCFP-EM) program is a 1-year enhanced skills program available to family medicine graduates interested in emergency medicine. Strong mentorship relationships were thought to assist residents with navigating the challenges of this program. Over the past 4 years, the CCFP-EM program at one academic centre initiated a novel mentorship program that matches residents with staff physicians in three areas of mentorship: clinical, research, and personal. This study aimed to determine the program success and areas for improvement. Methods: We conducted a cross-sectional study through an online survey distributed to all CCFP-EM residents and staff mentors from July 2015 to June 2019. Surveys included questions on the degree of satisfaction with the mentorship program, perceptions on the mentor/mentee experience, and areas for improvement. We asked staff and residents to rate their level of satisfaction with each mentorship component. Descriptive statistics were used to analyze satisfaction levels. Open-ended responses were analyzed for common themes. Results: 51.3% (19/37) of residents and 63.6% (35/55) of staff participated. For clinical mentorship, 68.5% of residents and 96.0% of staff rated the program as satisfactory/outstanding. For research mentorship, 73.7% of residents and 76.5% of staff rated the program as satisfactory/outstanding. The personal mentorship program was rated satisfactory/outstanding by 72.2% of residents and 95.3% of staff. Analysis for common themes revealed that continuity of support, development of autonomy, and opportunity for direct teaching were the main areas valued by residents. However, scheduling, teaching time, and mentor-mentee compatibility were the main challenges for residents. For mentors, scheduling was a main barrier to clinical mentorship, time constraint and resident commitment were the barriers to research mentorship, and resident engagement was the main barrier to personal mentorship. When asked which component(s) of mentorship should be continued for future residents, “personal mentorship only” was the most popular choice for staff (37.1%), while “mentorship in all three areas” was the most popular choice for residents (47.4%). Conclusion: Mentorship is an important aspect of the CCFP-EM program valued by staff and residents alike. Utilizing resident and staff feedback will allow for continuous improvement to the mentorship program.
P064: Hot days make for long stays: the impact of extreme heat events on emergency department lengths of stay and volumes in two Canadian community hospitals
Authors: Kegel F. , Luo O. , Richer S.
Published: May 2020

Introduction: The average temperature in Canada has risen 1.7°C between 1948-2016, increasing the frequency, severity and duration of extreme heat events. These events can exacerbate underlying health conditions, bringing patients to emergency departments (EDs). There is limited data associating sustained heat events to Canadian ED volumes and performance. This retrospective analysis assessed the impact of humidex and temperature on ED volume and length of stay (LOS). Methods: LOS is an indicator of ED overcrowding and system performance. The authors compared median and maximum LOS (hours) and patient volumes in both ambulatory and stretcher ED sections of two community hospitals (NDH, VH) in Montreal, QC to humidex and temperature during the summers of 2016-2018. Data were analyzed with one-way ANOVA and post hoc means analysis with Fisher LSD tests of a priori determined thresholds of mean three-day maximum humidex and temperature preceding ED presentation. Results: The mean maximum humidex and temperature values for the 2016-2018 summers in Montreal, QC were 30.4 and 26.1°C, respectively (n = 276 days). Elevated mean three-day maximum humidex was associated with increased ED volumes (F[3,88] = 4.2,p = 0.008) and median LOS (F[3,88] = 7.7,p = 0.0001) in the NDH. Mean three-day maximum humidex was associated with ED volumes (F[3,272) = 2.9,p = 0.03) but not with median and maximum LOS (p > 0.05) in the VH. Parallel comparisons with mean three-day maximum temperature similarly showed an association with increased ED volumes (F[3,88] = 5.0,p = 0.003) and increased duration of median LOS (F[3,88] = 3.5,p = 0.02) in the NDH. Mean three-day maximum temperature was associated with increased ED volumes (F[3,272] = 3.3,p = 0.02) but not with median and maximum LOS (p > 0.05) in the VH. Conclusion: Warming climates are associated with an increased number of ED presentations and longer median ED LOS. As heat events disproportionately impacted NDH, future investigations need to determine why these two hospitals were affected differently. This study provides local evidence that climate change can disrupt emergency services by increasing the demand for and delaying timely care. This is the first study that the authors are aware of that demonstrates these findings. Hospitals need to be climate ready. Heat waves often happen during times when summer bed closures and vacations already impact system capacity. EDs should dynamically adapt to meet community needs during periods of extreme heat.
P070: A systematic assessment of opioid-related advertisements aimed at emergency physicians in North America
Authors: Kirubarajan A. , Dragoman A. , Balakumaran J. , Got T. , Persaud N. , O'Neill B.
Published: May 2020

Introduction: The opioid epidemic has been influenced by immense marketing campaigns produced by pharmaceutical companies. These campaigns include advertisements aimed at emergency medicine (EM) physicians, which may have influenced overprescription. This study is a part of a larger effort to systematically assess opioid ads published in major medical journals in North America. To our knowledge, this is the first study to systematically assess the volume, claims, and levels of evidence for opioid ads aimed at EM physicians. Methods: Up to two issues per year from 1996 to 2016 of ten major North American medical journals were hand-searched for opioid advertisements. Specifically, we assessed random samples of issues from five major North American emergency medicine journals, including Annals of Emergency Medicine, Emergency Medicine, Canadian Journal of Emergency Medicine, Emergency Medicine Journal, and American Journal of Emergency Medicine. Five generalist medical journals were assessed including Journal of the American Medical Association, New England Journal of Medicine, Canadian Medical Association Journal, American Family Physician, and Canadian Family Physician. The volume of advertisements, nature of the claims, and cited evidence were collected by independent reviewers. The referenced evidence was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence rubric. Results: Of the 269 issues across the ten journals, opioid ads compromised 95 of the 3392 pharmaceutical advertisements with 79 opioid ads available for analysis. When analysis was completed with two reviewers, inter-rater agreement was rated as 99.87 (Cohen's kappa of 0.976). 37/79 ads did not mention the addictive potential of opioids, with 60/79 not mentioning the possibility of death. The tamper potential of medications was mentioned in 27/79 ads. Positive claims included efficacy (47/79), fast-acting ability (16/79), patient preference (5/79), convenience (26/79) and reduced side effects (22/79). 26/79 cited references directly in their text. Citations were provided for a total of 19 available original studies, of which a majority (16/19) were Level 2 evidence. Upon examination of conflicts of interest, 100% (19/19) of the referenced studies were funded by a pharmaceutical company. Conclusion: A variety of claims were published in medical journals through opioid advertisements, which cite industry studies. Many ads did not mention key negative information, which may have influenced EM physician prescribing.
P072: Preventing emergency department visits among patients with cancer: a scoping review
Authors: Kirkland S. , Clua M. Garrido , Junqueira D. , Campbell S. , Rowe B.
Published: May 2020

Introduction: Patients frequently present to the Emergency Department (ED) with predictable complications associated with radiation and chemotherapy for active cancer. Care alternatives have been proposed to reduce ED visits; however, no systematic review related to ED presentations has been completed. The objective of this scoping review was to examine the effectiveness of interventions designed to reduce ED visits among patients receiving active cancer treatment. Methods: A comprehensive literature search involving nine electronic databases and the grey literature was completed. Inclusion criteria considered studies assessing the impact of any intervention to reduce ED utilization among patients with active cancer. Two reviewers independently assessed relevance and inclusion; disagreements were resolved through third party adjudication. Dichotomous and continuous outcomes were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs) using a random-effects model, wherever appropriate. Results: From 3303 citations, a total of 25 studies were included. Interventions identified in these studies comprised: routine and symptom-based patient follow-up, oncology outpatient clinics, early symptom detection, comprehensive inpatient management, hospital at home, and patient navigators. Six out of eight studies assessing oncology outpatient clinics reported a decrease in the proportion of patients presenting to the ED. A meta-analysis of three of these studies did not demonstrate reduction in ED utilization (RR 0.78; 95% CI: 0.56 to 1.08; I2 = 77%) when comparing oncology outpatient clinics to standard care; however, sensitivity analysis removing one study reporting rare events supported a decrease in ED visits (RR 0.86; 95% CI: 0.74 to 0.99; I2 = 47%). Three studies assessing patient follow-up interventions showed no difference in ED utilization (RR 0.69; 95% CI: 0.38 to 1.25; I2 = 86%). Conclusion: A variety of interventions designed to mitigate ED presentations by patients receiving active cancer treatment have been developed and evaluated. Limited evidence suggests that an oncology outpatient clinic may be an effective strategy to reduce ED utilization; however, additional high-quality studies are needed.
P076: Assessment of a newly integrated and standardized approach for pediatric concussions aimed to improve the concussion recovery process
Authors: St.Onge J. , Karreman E. , McCarron M. , Harasen L. , Ames C.
Published: May 2020

Introduction: Children with concussions presenting to emergency departments often receive very different recommendations for how to recover. In addition, there are no instructions for teachers to how children should return to learn and play after a concussion. Therefore, some children take too long to return to learn and play at school while others return too soon, thereby risking long-term problems because their brain injury is not fully healed. The purpose of this project is to determine the impact of a new integrated, standardized approach aimed to help a concussed child recover faster and whether the recovery experience for all involved has improved. Methods: Structured interviews were conducted with 11 parents of children treated for concussion at the Emergency Department of Pasqua Hospital in Regina, SK, four of whom received care after a change in practice whereby parents were provided with a return-to-school protocol form prior to discharge. Data were analyzed using an inductive qualitative content analysis approach using NVivo 12 software. Results: Three main categories were noted in the data: Parental response to the child's concussion, satisfaction with health services, and the communication amongst parents, physicians, and teachers. It was with regard to the last theme in particular that the impact of the return to school protocol was noted, helping to at least indirectly address the issue of the parent as the “middleman” in the communication triad. Most parents whose children received care prior to the introduction of the protocol suggested that providing written information at discharge to guide parents through the concussion recovery process would be helpful. Conclusion: Our initial results show a positive impact in regards to the process of children returning to learn and play after a concussion. Specifically, the increased communication between physician, teacher, and parent seems to benefit and improve the child's recovery process.
P084: Hard-to-reach populations and administrative health data: a serial cross-sectional study and application of data to improve interventions for people experiencing homelessness
Authors: Hossain R. , Ma Z. , Dai J. , Jamani S. , Hossain R. , Strobel S. , Burcul I.
Published: May 2020

Introduction: Administrative data can aid in study and intervention design, incorporating hard-to-reach individuals who may otherwise be poorly represented. We aim to use administrative health data to examine emergency department visits by people experiencing homelessness and explore the application of this data for planning interventions. Methods: We conducted a serial cross-sectional study examining emergency department use by people experiencing homelessness and non-homeless individuals in the Niagara region of Ontario, Canada. The study period included administrative health data from April 1st, 2010 to March 31st, 2018. Outcomes included number of visits, number of unique patients; group proportions of Canadian Triage and Acuity Scale (CTAS) scores; time spent in emergency; and time to see an MD. Descriptive statistics were generated, and t-tests were performed for point estimates and a Mann-Whitney U test for distributional measures. Results: Our data included 1,486,699 emergency department visits. The number of unique people experiencing homelessness ranged from 91 in 2010 to 344 in 2017, trending higher over the study period compared to non-homeless patients. The rate of visits increased from 1.7 to 2.8 per person. People experiencing homelessness tend to present later in the day and with higher overall acuity as compared to the general population. Time in emergency department and time to see an MD were greater among people experiencing homelessness. Conclusion: Administrative health data allows researchers to enhance interventions and models of care to improve services for vulnerable populations. Given the challenging fiscal realities of research, our study provides insights to more effectively target interventions for vulnerable populations.
P089: Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review
Authors: Grant K. , Lee D. , Cheng I. , Baker G.
Published: May 2020

Introduction: Emergency Department (ED) crowding is an international health system issue that is worsening. Further, ED crowding and “hallway medicine” has been identified as one of the most significant healthcare challenges currently facing Canadians. One contributor is preventable transfers from long-term care facilities (LTCFs) to Emergency Departments (EDs). In Canada, there were 63,752 LTCF patient transfers to the ED in 2014, with 24% (15,202) of them due to potentially preventable conditions. Each preventable transfer exposes patients to transport and hospital-related complications, and costs the healthcare system thousands of dollars. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions in a systematic manner. Methods: A scoping review of the literature using three electronic databases was conducted. A scoping review methodology was used due to the range of interventions and the heterogeneity in study design and outcome. Inclusion criteria included: studies on interventions designed to reduce transfers from LTCFs, studies that reported key outcomes such as number of ED transfers, and studies with a control or comparison group. Articles were screened by two independent reviewers (Cohen's k = 0.68), and study quality was assessed using the National Heart, Lung, Blood Institute quality assessment tools. Results: Findings were organized into five intervention types (telemedicine, outreach teams, interdisciplinary teams, integrated approaches, and other), and both a tabular and narrative synthesis was completed. Eleven studies had a good quality assessment rating, 13 studies had a fair rating, and two studies had a poor rating. Twenty out of the 26 studies reported statistically significant reductions in ED transfer rate, ranging from 10-70%. Interdisciplinary healthcare teams staffed within LTCFs were the most effective interventions. Conclusion: There are several promising interventions that have successfully reduced the number of preventable transfers from LTCFs to EDs, in a variety of health system settings. Further analysis of the relative resource requirements of each intervention, and practices that can enable successful implementation are needed to inform healthcare policy and administrative decision making. Widespread implementation of these interventions has the potential to considerably reduce ED crowding.
P096: Non-legislative interventions to promote helmet use in adult cyclists: a scoping review
Authors: Javidan A. , Kirubarajan A. , Lee D. , Porplycia D. , Friedman S.
Published: May 2020

Introduction: Helmets are effective in preventing brain injury and fatality in cyclists. Methods to promote their use include legislation and non-legislative interventions (NLIs) such as education, social interventions, and subsidies. These have been systematically reviewed and proven effective in pediatric populations. We conducted a scoping review regarding NLIs to promote helmet use amongst adult cyclists. Methods: We conducted a scoping review of NLIs to promote helmet use amongst cyclists age 18 or older. PRISMA guidelines were followed. Databases searched included MEDLINE, EMBASE, CINAHL, PsycINFO, and SportDiscus, in addition to grey literature. Articles were excluded if non-English, focused on age <18, on legislative interventions, or did not report on outcomes related to helmet use or ownership. Study inclusion and data extraction were conducted in duplicate. Data were extracted regarding participant demographics, setting, intervention details and effects, and were reported using descriptive statistics with a narrative synthesis. A limited quality assessment was conducted. Results: A total of 16 papers were included, stratified as 4 randomized-controlled trials and 12 pre-post studies. Only 4 were specific to adults. Community cyclists (5/16, 31%) and community members were most commonly targeted, with most interventions taking place in the community (8/16, 50%) or in a healthcare setting (4/16, 25%). Most interventions were multi-faceted, involving components of community awareness programs, education, information distribution, helmet giveaways and monetary incentives, use of mass media, motivational interviewing, and social marketing. The studies were heterogeneous in quality. Changes in helmet rate use varied between -6% and 26%, with half the studies (8/16, 50%) noting a statistically significant increase. Duration of follow-up of helmet use rates following the intervention varied between 4.5 weeks and 11 years (median 1.38 years, mean 3.0 years.) Conclusion: NLIs to encourage bicycle helmet use were frequently multi-faceted and generally associated with an increase in use amongst adults. Studies were heterogenous in quality, varied in their targeted audiences and often not focused on adults. Further evidence is needed to better characterize the efficacy of non-legislative interventions to achieve sustained helmet use in adult cyclists.
P107: Use of activity trackers to count steps of older emergency department patients: a feasibility and validity study
Authors: Estrada-Codecido J. , Lee J. , Chignell M. , Whyne C.
Published: May 2020

Introduction: Mobility is an evidence-based non-pharmacologic strategy shown to reduce delirium and functional decline among older patients in the acute care setting. Activity trackers have been used in previous studies to objectively measure mobility in older hospitalized patients. This study aims to compare the feasibility and validate the accuracy of three accelerometer-based activity trackers (Fitbit Zip, Fitbit Charge HR and StepWatch). This is the first step in a program of research to objectively measure as a potential marker of delirium risk. Methods: This is a prospective study of patients 65 years of age and older during their ED visit. We excluded those with critical illness, unable to communicate or provide consent; and any ambulatory impediments. Consenting participants wore the trackers for up to 8 hour, and completed a 6-meter walk test while a research assistant manually counted their steps. Our primary feasibility measure was the proportion of eligible patient for which we were able to recover the tracker and recorded their steps. The primary validation endpoint was the concordance between steps recorded by the tracker compared to a gold standard manual step count over a fixed distance. Sample size was based on the desired precision of the final estimate of feasibility. Intraclass correlation coefficient (ICC) was calculated to assess agreements between devices and manual count. We will report proportions with exact binomial 95% confidence intervals (CI) for feasibility and validity endpoints. Results: 41 participants were enrolled in this study. Mean age was 74.6 years (+/- 5.76) and 59% were females. The total subjects that wore the Fitbit Zip, Fitbit Charge HR and StepWatch during study participation was, 40/41 (97.5%, CI 0.87–0.99), 33/34 (97%, CI 0.84–0.99) and 31/32 (96.8%, CI 0.83–0.99), respectively. Total subjects with completed data extracted from the Fitbit Zip, Fitbit Charge HR and StepWatch was, 38/41 subjects (92.6%, CI 0.80–0.98), 34 (100%, CI 0.89–1.00), and 32 (100%, CI 0.89–1.00), respectively. All devices were recovered after use (100%, 95%CI 0.91–100). Conclusion: Our results suggest: 1) the use of gait-tracking devices in the ED is feasible, 2) consumer and research-grade devices showed good validity against the gold standard, and 3) the use of small, inexpensive, consumer-grade trackers to objectively measure mobility of older adults in the ED.
P109: Does an elevated troponin ultimately matter? An assessment of outcomes in patients presenting to the emergency department with non-cardiac complaints
Authors: Endres K. , Chow B. , Garuba H.
Published: May 2020

Introduction: Acute myocardial infarction (MI) is one of the most time-sensitive diagnoses made in the emergency department (ED). Troponin (TNI) measurement is an invaluable tool; however, its utility depends on the clinical context and is highest where there is a strong pre-test probability. Studies show that most TNI elevations are due to non-cardiovascular causes; however, elevated TNI has been associated with increased morbidity and mortality, often prompting additional investigations. The aim of our study was to compare 1-year cardiac outcomes of patients who presented to the ED with non-cardiac complaints and elevated TNI who had further cardiac testing versus those who did not. Methods: We conducted a retrospective chart review of patients ≥18 seen in the ED for non-cardiac complaints with a high TNI from January-June 2016. Patients were stratified into two groups: 1) those who received diagnostic testing for ischemia and/or a cardiac consultation and 2) those without cardiac consultation or testing. Data was also collected on major adverse cardiac events within 1-year of ED presentation. Chi-squared analysis assessed the difference in proportions of outcomes between groups. We present our preliminary data. Results: In total, 1500 patients met inclusion criteria and 861 have been analyzed thus far. Of these 861, 209 went on to have either diagnostic testing for ischemia and/or a cardiology consult while 652 had no further investigations. There was no statistically significant difference in the proportion of patients who developed unstable angina (p = 0.9824), ST-elevation myocardial infarction (STEMI) (p = 0.9956), non-STEMI (p = 0.9008), stroke/TIA (p = 0.9657), revascularization (p = 0.8873), cardiac hospitalization (p = 0.9446) or died (p = 0.8972), within 1-year of their ED presentation. Conclusion: In patients with isolated elevated TNI and non-cardiac complaints, preliminary data showed no difference in mortality or cardiac event rates between those who had further testing/consultations and those who did not. TNI ordering could be cautiously limited to only presenting complaints/preliminary diagnoses likely to have cardiac etiology or sequelae or those in whom further testing would impact management/outcomes. Quality of care may be improved by reducing length of stay in the ED and potential risks of unnecessary tests. Future studies include determining cost implications and classifying what level of TNI elevation in non-ACS patients may predict a future cardiac outcome.
P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective
Authors: Doran P. , Sheppard G. , Metcalfe B.
Published: May 2020

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.
Just the Facts: how to teach emergency department flow management
Authors: Chan Teresa M. , Sherbino Jonathan , Welsher Arthur , Chorley Alexander , Pardhan Alim
Published: May 2020

Even before starting your evening shift you know it's going to be busy. Ambulances are lined up in front of the hospital, and the charge nurse already seems stressed out. The senior Emergency Medicine (EM) resident is standing in the physician office, ready to start her shift as well. You have worked with her a few times during this rotation. She is competent, you trust in her management plans for all her individual patients. Together you both review the patient tracker: a variety of patient presentations ready to be seen, plus an additional 20 patients in the waiting room. Negotiating the learning objective for the shift, the resident indicates that she would like to work on more efficiently managing patient flow and the administration of the emergency department (ED). But…isn't that a skill you just learn from experience? You wonder what evidence-informed strategies might exist for training her for this next step.
P117: A multicenter analysis of an emergency physician lead on department flow and the provider experience
Authors: Crowder K. , Domm E. , Lipp R. , Robinson O. , Vatanpour S. , Wang D. , Lang E.
Published: May 2020

Introduction: Emergency department (ED) flow is a strong predictor of patient safety, quality of care and provider satisfaction. Throughput interventions have been shown to improve flow metrics, yet few studies have considered MD leadership roles and evaluated provider experience. Our objective was to evaluate the emergency physician lead (EPL) role, a novel MD staffing initiative. Methods: This mixed-method observational time series analysis evaluated ED metrics at two tertiary EDs including ED length of stay (LOS), EMS Park LOS and physician initial assessment (PIA) time as well as 72-hour readmit and left without being seen (LWBS) rates. Data was collected from the ED information system database for control (Dec 6, 2017-Feb 28, 2018 SITE1 and Mar 1–May 31, 2018 SITE2), pre (Sept 3-Nov 30, 2018 SITE 1 and Dec 3, 2018-Feb 28, 2019 SITE2) and post (Dec 3, 2018 –Feb 28, 2019 SITE1, Mar 1- May 31, 2019 SITE2) periods for adult patients presenting to each site. Site data was analyzed independently using descriptive and inferential statistics to calculate differences in means, and means were compared using t-tests. A survey elicited provider feedback from ED physicians, nurses, and EMS professionals on the effect of the EPL on throughput, timeliness of admissions and discharges, provider workload, and the EPL as a resource to other professionals. Results: The number of ED visits at SITE1 were 13136 (Ctrl), 13236 (Pre) and 13137 (Post), and at SITE2 were 14371(Ctrl), 13866 (Pre) and 14962 (Post). Mean ED LOS was decreased by 17 min in post vs control and 20 min vs pre at SITE1 (p < 0.01). SITE2 saw an increase in ED LOS by 7 min vs control and 8 min vs pre (p < 0.01). EMS LOS at SITE1 was decreased by 21 min vs control and 22 min vs pre (p < 0.01), but was increased at SITE2 by 2 min vs control (p = 0.09) and 14 min vs pre (p < 0.01). PIA time at SITE1 was decreased by 15 min vs control (p < 0.01) and 13 min vs pre and increased by 5 min vs control and 12 min vs pre at SITE2 (p < 0.01). 72 hour readmit and LWBS rates were unchanged at both sites. Qualitative feedback from ED providers highlighted the early provision of treatments and investigations by the EPL, and many felt the EPL was an important resource. Conclusion: The inclusion of both quantitative and qualitative data in this study provided a robust analysis of the impact of the EPL role and demonstrated modest but important improvements. A site-dependent, carefully considered implementation of the EPL role may improve ED metrics and provider experiences.
P122: The evaluation of various point of care ultrasound features in Stanford type A aortic dissections
Authors: Chiang T. , Puri G.
Published: May 2020

Introduction: Type A aortic dissection(AD) is one of the most lethal diseases in medicine. Its mortality rate increases 1-2% per hour from the onset of symptoms to treatment. Timely diagnoses of ADs, therefore, are crucial to improve survival and decrease morbidity. There are various proposed clinical guidelines to help emergency physicians decide when a CTA is urgently needed with most widely quoted being the validated Aortic Dissection Detection Risk Score(ADD-RS) recommended by the American Heart Association. The addition of D-Dimer for further risk stratification has also been entertained. A recent article published in the American Journal of Emergency recommends using point of care ultrasound(POCUS) to expedite diagnosis. With the rising use of POCUS in the emergency department, it can be the missing link to timely AD diagnoses. This project aims to elucidate the prevalence of positive POCUS findings (pericardial effusion and dilated aortic root) in type A AD via a retrospective chart review. Methods: This study is a retrospective chart review of 200 patients with the diagnosis of AD treated at Southlake Regional Hospital. We included patients diagnosed with type A AD and excluded those diagnosed with type B AD. We collected data on their demographics, ADD-RS scores, investigation results, treatments, and clinical outcomes. The main focus of the chart review was on the presence of pericardial effusion or dilated aortic root on echocardiograms. Binomial statistical analysis was used to analyze the collected data. Results: We identified 126 patients with type A AD out of 200 charts reviewed. Thirteen (14% CI 8-23%, n = 93 p = 0.05) had wide mediastinum on their chest X-rays; twenty (95% CI 75-100%, n = 21 P = 0.05) had elevated D-dimer levels; and ninety-one (72% CI 64-80%, n = 126 p = 0.05) had positive ADD-RS. Only 88 out of 126 AD cases had documented echocardiograms. Sixty-eight (77% CI 67-86%, n = 88 p = 0.05) had either pericardial effusions or dilated aortic roots on their echocardiograms. Eighty-one (92% CI 84-95%, n = 88 p = 0.05) had either positive ADD-RS or positive echocardiogram findings, which is 20 (23% CI 14-33%, n = 88 P = 0.05) more cases than ADD-RS would have picked up alone. Conclusion: The absence of both pericardial effusion and dilated aortic root on echocardiogram in combination with a negative ADD-RS has a high sensitivity for ruling out type A AD. Our data support further research into the use of POCUS to expedite the diagnosis of type A AD in the emergency department.