bluuebunny/crossref_metadata_2025 huggingface dataset:
P114: Considering perceptions of patients and knowledge users in the design of an emergency-based acute asthma educational trial
Authors: Rowe B.H. , Villa-Roel C. , Majumdar S.R. , Couperthwaite S. , Rawe E. , Nikel T.
Published: June 2016

Introduction: Educational interventions driven by the needs of users can help move evidence into practice. This study considered the perceptions of patients and knowledge users in the design of an educational intervention in acute asthma directed from Emergency Departments (EDs). Methods: A mixed methods design with two phases was used. In phase I, convenience samples of asthmatics presenting to the University of Alberta Hospital ED and primary care providers (PCPs) from Edmonton were invited to participate in a survey. Perceptions with respect to: a) an ideal local opinion leader (OL) in ambulatory asthma care; and b) content, style and delivery methods of OL educational interventions in acute asthma were collected. In phase II, focus-group discussions were conducted to further explore preferences and expectations for such interventions; self-perceived barriers and facilitators for implementation were assessed. Results: Overall, 54 patients completed the survey; 39% preferred receiving guidance from a Respirologist, 44% during their ED visit and 56% through individual discussions. In addition, 55% expressed interest in having PCP follow-up within a week of discharge. A Respirologist was identified as an OL in ambulatory asthma by 59% of the 39 responding PCPs. All expressed interest in receiving notification of their patients’ ED presentation, most within a week and including diagnosis and ED/post ED-treatment. Personalized and guideline-based recommendations were considered to be the ideal content by the majority; 39% requested this guidance through an educational pamphlet faxed to their offices. In the focus groups, patients and PCPs recognized the importance of health professional liaisons in the ED to PCP transition of care; patient anxiety and time constraints were identified as potential barriers for ED-educational information uptake and proper post-ED follow-up, respectively. Conclusion: Messages arising from patients and PCPs help tailoring study interventions to meet local needs and expectations. Overall, patients and physicians are seeking ways to mitigate problems with transitions in care. This contact with the practice environment also facilitates the identification of potential determinants to implementation and knowledge uptake.
P118: The utility of serum markers for diagnosing septic arthritis in the emergency department: do rigid cut-offs improve diagnostic characteristics?
Authors: Shaw B.H. , Logan E. , Lang E. , Fedwick J.
Published: June 2016

Introduction: Septic arthritis represents one of the most severe diagnoses for a presentation of an acutely swollen joint, with a high level of morbidity and mortality associated with delayed management. There is continued interest in the utility of serum markers of inflammation in diagnosing this dangerous condition, however there is a lack of clear consensus for cut-offs that optimize diagnostic performance for these tests. The objective of this study was to perform a systematic search of the literature to identify optimal cut-offs for commonly ordered serum markers and to assess how these cut-offs perform in a cohort of patients with a diagnosis of septic arthritis. Methods: We performed a systematic literature search aimed at identifying optimal cut-offs for serum makers (white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) used for diagnosing septic arthritis. We assessed the use of these markers within a retrospective cohort (n=87) of patients diagnosed with septic arthritis (based on positive gram stain, culture, or treatment with a prolonged antibiotic course and/or surgical intervention) that presented to one of four emergency departments in Calgary over a two-year period. We then compared published values to local data. Results: We identified 10 articles that evaluated diagnostic characteristics for serum markers. Although there was variability for cut-offs reported in the literature, classically WBC >11 x 109/L, ESR >30 mm/h, and CRP >100 mg/L were reported to modestly increase the likelihood ratio of diagnosing septic arthritis. In our cohort, a complete blood count was ordered in the emergency department in 97% (n=84) subjects. ESR and CRP were ordered in 66% (n=57) and 85% (n=74) of patients, respectively. When comparing the classic literature based cut-offs to our population group, a WBC <11 x 109/L was found in 38% (n=32), ESR <30 mm/h in 51% (n=38), and CRP <100 mg/L in 30% (n=17). Sensitivity was found to be poor (61% for WBC >11 x 109/L; 70% for ESR >30 mm/h; 48% for CRP >100 mg/L). Conclusion: Data collected from the Calgary Emergency Department supports the published literature suggesting that serum tests are not helpful in the diagnosis of septic arthritis. Future work should evaluate these diagnostic characteristics in relation to patients with non-infectious monoarticular joint pain.
P126: Analysis of acute pain management in the emergency department of a large private hospital in Cape Town, South Africa
Authors: Stander M.
Published: June 2016

Introduction: Pain is a common presenting complaint amongst emergency department (ED) patients. Evidence suggests that pain is often inadequately and inconsistently treated resulting in oligoanalgesia. Patients that do not have their pain timeously recognised and treated end up with an inferior patient experience in the ED. It was speculated that pain management in Panorama Mediclinic ED was not optimal and an in-depth analysis of pain management trends was performed in order to lead to a targeted intervention which would result in better care in the ED. Methods: A convenience sample of 100 random folders was collected from May-July 2015. Folders with presenting complaints excluding pain and children under 10 years of age were excluded. The data were collected onto a password protected Excel database and analysed using basic descriptive analysis. Results: 44% of patients included were green triage category, 30% yellow, 23% orange and 1% red. 82% of patients presented with verbal pain scores greater than 5/10. The average time to receive analgesia was 60.26 minutes. 33.3% of patients only received analgesia after being in the ED for >60 minutes. Of those patients receiving delayed analgesia, the majority of their pain scores were between 6-8/10. Abdominal and extremity pain together consisted of 51% of the anatomical pain distribution. 29% of the patients sampled received no analgesia during their visit to the EC and the majority of their pain scores were between 3-6/10. Intravenous acetaminophen, intravenous opioids and intramuscular opioids are by far the most common pharmaceutical agents to treat acute pain in this ED. Conclusion: This study demonstrated that acute pain is not well managed in the ED of Panorama Mediclinic. Subsequently an acute pain management protocol was implemented in which all patients with pain scores greater than 5/10 are offered early analgesia on initial presentation to the ED by the triage nurse.
P127: Use of nt-probnp biomarker amongst cardiologists and emergency physicians to diagnose acute heart failure in the undifferentiated dyspneic emergency patient
Authors: Steinhart B. , Levy P. , McGowan M. , Mazer C.
Published: June 2016

Introduction: Diagnosing the undifferentiated dyspneic emergency department (ED) patient remains a challenge for clinicians; in order to rule in or out acute heart failure (AHF) natriuretic peptide biomarker testing has evolved and is recommended by cardiology international guidelines to be utilized in these presentations. However there is equipoise in the emergency community for its use, largely due to perceived modest test specificity. We sought to analyze this apparent clinical dichotomy as part of a multicenter trial of undifferentiated dyspneic ED patients. Methods: Patients with dyspnea presenting between October 2010 and October 2013 to one of four ED sites -2 Canadian, 1 American, 1 New Zealand- were assessed by certified staff emergency physicians (EPs) and their chest Xray reviewed. Those patients with undifferentiated dyspnea with a potential for AHF (ie further investigated or treated for AHF but investigated and/or treated for another cause) were consented and enrolled. Two of the sites (American, New Zealand) had NT-proBNP assay ordered as a standard of care for these patients; the other 2 sites did not. At the end of Emergency care, the EP recorded the primary diagnosis of the dypnea-either “AHF” or “Not AHF.” Blinded adjudication was carried out by 2 cardiologists after reviewing sequential records: first, with index ED records but no NT-proBNP result; second, with the NT-proBNP result and lastly, with follow up 60 day records (deemed the gold standard diagnosis). EP accuracy between NT-proBNP and no NT-proBNP sites and NT-proBNP accuracy using standard cutpoints were calculated, as were the number of adjudicated cases influenced by exposure to NT-proBNP. Results: 197 patients were enrolled, 107 at NTproBNP sites and 90 at the other 2 sites. EP accuracy was 76% for either site. NT-proBNP used as a binary test with recommended age-stratified cutoffs had 80% accuracy, applied to 70% of patients (30% remained in “gray zone”).Cardiology adjudicators reversed 16% of initial diagnoses upon exposure to NT-proBNP result, ultimately diagnosing 41% of patients with AHF. Conclusion: This study supports the clinical equipoise amongst emergency physicians compared to cardiologists for the use of NT-proBNP in diagnosing acute heart failure in the undifferentiated dyspneic Emergency patient.
P134: Evaluating barriers to clinical decision rule integration: a qualitative analysis
Authors: Trumble D.E.
Published: June 2016

Introduction: Clinical decision rules for computed tomography (CT) ordering in pulmonary embolism and mild traumatic brain injury have been shown to be under-used in clinical practice. Current literature does not explain why these validated decision rules continue to be under-used despite evidence of inappropriate use and increased costs. To better evaluate potential barriers to their use, qualitative methods involving focused interviews were conducted amongst emergency department (ED) physicians. Methods: Physicians were recruited via a brief presentation at Calgary Zone ED rounds. Ten attending and resident physicians (4 female, 6 male) were interviewed. Questions were designed to evaluate potential barriers to the integration of decision rules into the computerized order entry system. Interviews were audio-recorded and transcribed manually. A high-level thematic analysis was conducted to draw primary themes from open-ended questions, and responses were totaled for closed-ended questions. Results: Emerging themes suggest concerns surrounding timing of rule application in relation to test ordering, patient influences on ordering, and overuse reporting. All 10 physicians believed decision rules for CT ordering play a large role in the ED, and 8 were in favor of integration into the order entry system. However, over half expressed concern, noting that their thought process begins before order entry. A majority prioritized shared decision-making with patients. However, 8 indicated that patient expectations influence their ordering. A majority agreed that there is CT overuse in the ED, but many were hesitant in concluding that overuse was primarily physician dependent. Conclusion: Primary barriers to decision rule integration are timing of application, hesitation surrounding patient input, and uncertainty over data. Physicians often make decisions prior to order entry. Mobile copies of decision rules should be available to better facilitate compliance. Concerns over patient influence on ordering are common. Patient-friendly materials on clinical decision rules should be available to better facilitate shared decision making while still promoting decision rules. While overuse is agreed upon, many prefer to see and track their own ordering data before supporting a physician-targeted intervention. Data reports to physicians may help affirm physician-associated overuse, and reinforce their role in responsible resource utilization.
P142: The anticoagulated trauma patient: a Canadian experience in the era of direct oral anticoagulants
Authors: Wood B. , Ackery A. , Rizoli S. , Nascimento B. , Sholzberg M. , Mcfarlan A. , McGowan M. , Phillips A.
Published: June 2016

Introduction: The anticoagulated trauma patient is a particularly vulnerable population. Our current practice is guided by experience with patients taking vitamin K dependent antagonists (VKA, like warfarin). It is currently unknown how the increasing use of direct oral anticoagulants (DOACs) will change our trauma population. We collected data about this new subset of patients to compare their clinical characteristics to patients on pre-injury VKA therapy. Methods: Retrospective review of anticoagulated trauma patients presenting to Toronto’s two adult trauma centres, Saint Michael’s Hospital and Sunnybrook Health Sciences Centre, from June 2014-June 2015 was undertaken. Patients were recruited through the institutions’ trauma registries and were eligible if they suffered a traumatic injury and taking an oral anticoagulant pre-injury. Clinical and demographic data were extracted by a trained reviewer and analysed with descriptive statistics. Results: Our study recruited 85 patients, 33% were taking DOACs and 67% VKAs. Trauma patients on DOACs & VKAs respectively had similar baseline characteristics such as age (75.9 vs 77.4), initial injury severity score (ISS (16.9 vs 20.6)) and concomitant antiplatelet use (7.1% vs 5.4%). Both groups’ most common mechanism for injury was falls and the most common indication for anticoagulation was atrial fibrillation. Patients on DOACs tended to have lower average INR (1.25 vs 2.3) and serum creatinine (94.9 vs 127.4). Conclusion: Patients on DOACs pre-injury now account for a significant proportion of orally anticoagulated trauma patients. Patients on DOACs tended to have less derangement of basic hematological parameters complicating diagnosis and management of coagulopathy.
P143: Retrospective review of microbiology results in adult patients presenting to the emergency department with acute epididymitis
Authors: Rogenstein C. , Worrall J. , Taylor I. , Perry J.J.
Published: June 2016

Introduction: North American practice guidelines for empiric antibiotic selection in the treatment of epididymitis are based on very small studies. These guidelines recommend antibiotic selection based on age. This study’s objective was to determine if culture results in a Canadian emergency department population with acute epididymitis support these guidelines. Methods: We conducted an electronic health records review ED patients with a discharge diagnosis of epididymitis. All patients who presented to two emergency department sites of the Ottawa Hospital from 2012 through 2014 were included. Data collected were patient age, urine culture results, results of urine or urethral swab nucleic acid amplification test (NAAT) for gonorrhea or chlamydia, and results of scrotal ultrasound. Ultrasound radiology reports were independently reviewed by two authors and classified as positive, negative, or indeterminate. Results: We identified 379 cases of epididymitis. There were 169 patients aged 18-35 years, and 202 patients over 35 years. The rates of positive urine culture, in the under 35 and over 35 population respectively, were 5% and 42% (p<.0001). The rates of positive NAAT were 10% and 4% (p=.43). Ultrasound was performed in 252 patients; 160 (63%) were positive. There was no significant difference in the rates of positive urine culture or NAAT between the ultrasound-positive patients and patients who had negative, indeterminate, or no ultrasound. Conclusion: Our findings are not concordant with clinical practice guidelines. While the over 35 age group had a statistically higher rate of positive urine culture, the rate of positive NAAT was not different from the younger group. Both urine culture and NAAT are usually negative in the under 35 group. Positive culture rates are not higher in the subgroup of ultrasound “proven” epididymitis. Physicians should exercise clinical judgement in selecting empiric antibiotics for patients with epididymitis; basing choice on patient age alone may not be appropriate.
LO002: Improving safety of patients in respiratory distress: identifying preventable adverse events related to care provided in the emergency department
Authors: Pretty S. , Scaffidi Argentina S. , Vaillancourt C. , Perry J.J. , Stiell I.G. , Forster A. , De Gorter R. , Calder L.A.
Published: June 2016

Introduction: Patients with acute exacerbations of heart failure (HF) or chronic obstructive pulmonary disease (COPD) may be at high risk for preventable adverse events (AEs). Preventable AEs are ED care-associated complications due to medical error. Our objective was to identify and characterize preventable AEs among ED patients over 50 presenting with dyspnea from an acute exacerbation of HF or COPD; who were subsequently admitted or discharged. Methods: We conducted a multicentre health records review from six academic centers in Ontario and Alberta. We analysed health records for all prospectively enrolled patients who experienced flagged outcomes: relapse to ED within 14 days requiring admission; admission to a monitored unit (AMU), cardiac care unit(CCU), or intensive care unit(ICU); intubation(ETI); non-invasive ventilation(NIV); diagnosis of acute myocardial infarction(AMI); or death within 30 days. Using a validated approach, an ED physician analyzed case summaries for flagged outcomes that were associated with ED care, designated as AEs. Preventable AEs had contributing errors in diagnosis, management, procedure, medications or unsafe disposition decisions. We analyzed these data using thematic coding and descriptive statistics. Results: Of 2,515 patients enrolled (1,100 HF and 1,415 COPD), 210 patients experienced flagged outcomes, 47.1% of which were female, 64.3% had HF and the remaining COPD. The majority (86.2%) of flagged outcomes were related to underlying disease, but 13.8% of cases met criteria for AE and all were deemed preventable. Of the identified AEs, 72.4% returned to the ED and required admission to hospital; 17.2% were admitted to ICU, CCU, or AMU; 6.9% of patients died; 3.4% were intubated; 3.4% had a diagnosis of AMI and 0% required NIV. We found 75.8% of preventable AEs resulted from a management error (eg. not prescribing steroids on discharge for moderate COPD exacerbation); 31.0% from an unsafe disposition decision and 10.3% of AEs resulted from diagnostic error. Conclusion: Patients with acute exacerbations of HF and COPD are at high risk of preventable AEs directly related to care provided in the ED. Management and disposition decisions were a concerning source of error and should compel and focus future quality improvement efforts.
LO005: Association between emergency department chest pain volume and outcomes among patients presenting with chest pain
Authors: Dattani N.D. , Koh M. , Chong A. , Czarnecki A. , Ko D.T.
Published: June 2016

Introduction: Chest pain is one of the most common reasons for emergency department (ED) visits in developed countries. Patients discharged after ED assessment remain at risk for adverse cardiac events. Although a volume-outcome relationship has been shown for myocardial infarction, it is uncertain whether a similar relationship exists with ED chest pain volume. Accordingly, we aimed to determine whether ED chest pain volume influences outcomes of patients presenting to the ED with chest pain who were discharged home. Methods: This was a retrospective cohort study using population-based data from Ontario, Canada. Patients who were discharged home from an ED in Ontario with a primary diagnosis of chest pain from April 1, 2004 to March 31, 2010 were included. High-risk patients were defined as the presence of diabetes or pre-existing cardiovascular disease, while low-risk patients were defined as the absence of these conditions. ED volume was categorized as low, medium, or high, based on tertiles of annual chest pain patient volume. The primary outcome of this study was all-cause mortality one year after the index ED visit. Mantel-Haenszel Chi-Square was used to compare crude outcome rates. Results: There were 56,767 high-risk patients. The average age was 66 years and 53% were male. All-cause mortality rates were 6.8%, 6.3%, and 6.0% (p=0.028), and rates of hospitalization for acute coronary syndrome were 5.8%, 4.6%, and 4.0% (p<0.001) among low, medium, and high volume EDs respectively. There were 216,527 low-risk patients. The average age was 64 years and 42% were male. All-cause mortality rates were 2.0%, 1.9%, and 1.6% (p<0.001), and rates of hospitalization for acute coronary syndrome were 1.5%, 1.4%, and 1.0% (p<0.001) among low, medium, and high volume EDs respectively. Conclusion: Higher volume EDs were associated with decreased rates of all-cause mortality and admission for acute coronary syndrome among chest pain patients who were discharged home. Future research should study the reasons for this finding and attempt to improve outcomes in lower volume EDs.
LO019: The prevalence and characteristics of non-transported EMS patients in Nova Scotia
Authors: Carrigan S.A. , Asada Y. , Travers A. , Goldstein J. , Carter A.
Published: June 2016

Introduction: An undefined yet potentially significant risk for Emergency Medical Services (EMS) systems are patients who access 911 with an ambulance response who are not transported to hospital (non-transport). Our objective was to determine the prevalence and associated characteristics of non-transport and potentially clinically adverse non-transports in Nova Scotia. Methods: We conducted a secondary analysis of pooled cross-sectional, population-based administrative data in a provincial EMS system that provides care to 920,000 residents. Electronic patient care record (ePCR) data was retrospectively analyzed for one calendar year (2014). The dependent variables were non-transport status and potentially adverse non-transport status. Potentially adverse non-transports were defined as a repeat call within 48 hours for a related complaint with the outcome of transport or death. Independent variables include patient characteristics, (age, sex, vitals and paramedic clinical impression), operational (crew type and response code) and environmental (time, date, and location). For both objectives we determined the prevalence of the outcome of interest, and associated characteristics. Results: There were 74,471 EMS responses between January to December 2014, 18.9% (n=14, 094/74,471) resulted in a non-transport. The characteristics most associated with non-transport are: age, paramedic clinical impressions, number of co-morbidities, response mode, and incident location type. As age decreased, the likelihood of non-transport increased. Younger non-transported patients (0-15 years old) (OR 2.2, 99.9% CI 1.9-2.5) are more likely to have non-transport. Relative to other paramedic clinical impressions, glycemic issues (OR 4.8; 99.9% CI 3.9-5.7) and wellness checks (OR 6.5; 99.9% CI 5.7-7.3) are more likely to have a non-transport. Non-transports are more likely at a detention facility (OR 4.1; 99.9% CI 3.2-5.1) or a roadway (OR 2.4; 99.9% CI 2.1-2.8). 5.6% (n=798/14094) of non-transport patients were classified as a potentially adverse non-transport. Conclusion: This study demonstrated that a significant portion of patients (18.9%) had a non-transport outcome, but only a small percentage (5.6%) were considered potentially adverse. The results of this study provide timely information to policy makers and healthcare practitioners on the scope of this issue, and suggest potential directions for future study and clinical decision making.
LO022: Incidence and impact measurement of delirium induced by ED stay - INDEED
Authors: Émond M. , Voyer P. , Daoust R. , Pelletier M. , Gouin E. , Berthelot S. , Boucher V. , Giroux M. , Lamontagne M. , Lee J.S. , Le Sage N. , Lemire S. , Moore L.
Published: June 2016

Introduction: Delirium is a dreadful complication in seniors’ acute care. Many studies are available on the incidence of delirium, however ED-induced delirium is far less studied. We aim to evaluate the incidence and impact of ED-induced delirium among older non-delirious admitted ED patients who have prolonged ED stays (≥ 8 hours). Methods: This prospective INDEED study phase 1 included patients recruited from 4 Canadian EDs. Inclusion criteria: 1) Patients aged 65 and over; 2) ED stay ≥ 8 hours; 3) Patient is admitted to the hospital; 4) Patient is non-delirious upon arrival and at the end of the first 8 hours; 5) Independent or semi-independent patient. Eligible patients were assessed by a research assistant after an 8 hour exposition to the ED and evaluated twice a day up to 24h after ward admission. Patients’ functional and cognitive status were assessed using validated OARS and TICS-m tools. The Confusion Assessment Method was used to detect incident delirium. Hospital length of stays (LOS) were obtained. Univariate and multivariate analyses were conducted to evaluate outcomes. Results: Of the 380 patients prospectively followed, mean age was 76.5 (± 8.9), male represent 50% and 16.5% very old seniors (> 85 y.o.). The overall incidence of ED-induced delirium was 8.4%. Distribution by the 4 sites was: 10%, 13.8%, 5.5% & 13.4%. The mean ED LOS varied from 29 to 48 hours. The mean hospital LOS was increase by 6.1 days in the delirious patients compared to non-delirious patient (p<0.05). Increase mean hospital LOS distribution by site was by: 6.9, 8.5, 4.3 and 5.2 days for the ED-induced delirium patients. Conclusion: ED-induced delirium was recorded in nearly one senior out of ten after a minimal 8 hour exposure in the ED environment. An episode of delirium increases hospital LOS by about a week and therefore could contribute to ED overcrowding.
LO026: Outcomes of a provincial cardiac reperfusion strategy: a population-based, retrospective cohort study
Authors: Cook J. , Carter A. , Travers A. , Brown R. , Cain E. , Swain J. , Jensen J. , Goldstein J. , Lee T.
Published: June 2016

Introduction: Nova Scotia has a province wide reperfusion strategy for the treatment of patients presenting with acute ST-Elevation Myocardial Infarction (STEMI). Patients are referred for primary percutaneous coronary intervention (PPCI) if a first medical contact to device time can be achieved within 90 to 120 minutes; otherwise, fibrinolytic therapy is administered, as per guideline recommendations. Since 2011, Nova Scotian paramedics have been providing prehospital fibrinolysis (PHF) and prehospital catheterization (cath) lab activation for STEMI patients outside and within the PPCI catchment area, respectively. Patients who received fibrinolysis are transferred to a PCI facility if rescue PCI is required or if there are other indications for urgent intervention. This province wide approach is unique and the objective of this retrospective cohort study is to compare the impact of this approach on the primary outcome of 30-day mortality. Methods: For the study period, July 2011 to July 2013, STEMI patients who were diagnosed prehospital or in the ED who subsequently underwent reperfusion therapy were identified in the Emergency Health Services (EHS), Cardiovascular Information Systems (CVIS) and Cardiovascular Health Nova Scotia (CVHNS) databases. Baseline demographics and outcomes were then compared according to the treatment received: 1) PHF; 2) ED Fibrinolysis (EDF); 3) prehospital activated PPCI (EHS PPCI); and 4) ED activated PPCI (ED PPCI). Results: There were a total of 1107 STEMI patients identified during the study period, of whom 742 received lytic therapy (146 PHF; 596 EDF) and 332 underwent PPCI (202 EHS PPCI; 130 ED PPCI). Demographic variables were similar across the groups. The primary outcome of 30-day mortality was not significantly different across groups: 5 (3%) in PHF, 26 (4%) in EDF, 8 (4%) in EHS to PPCI and 2 (2%) in ED to PPCI. The number of rescue PCIs was 28 (19%) in PHF and 102 (17%) in EDF. Other outcomes (key timestamps) are pending. Conclusion: Our results show that the 30-day mortality was lowest for patients undergoing PPCI and slightly less for patients receiving pre-hospital fibrinolytic compared to those receiving ED fibrinolytic with no difference in the proportion requiring subsequent rescue PCI. The majority of patients in rural areas received EDF as opposed to PHF; pending results will show if this represents a delay in patient presentation after symptom onset.
LO028: Prospective validation of an iOS app to evaluate tremor in patients with alcohol withdrawal syndrome
Authors: Borgundvaag B. , McLeod S.L. , Dear T.E. , Carver S.M. , Norouzi N. , Bromberg S. , Kahan M. , Gray S.H. , Arabi P.
Published: June 2016

Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Among the domains assessed by the CIWA-Ar, tremor is the most objective indicator of withdrawal severity, however, the ability of clinicians to reliably quantify tremor is highly dependent on experience. The objective of this study was to prospectively validate an objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application. Methods: A prospective observational study of patients ≥18 years presenting to an academic emergency department in alcohol withdrawal was conducted from Oct 2014 to Aug 2015. Assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Accelerometer derived results were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 76 patients with 78 tremor recordings were included. Accelerometer derived tremor scores matched exactly with expert assessor scores in 36 (46.2%) cases, within 1 point for 73 (93.6%) cases and differed by ≥ 2 points in 5 (6.4%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘very good’ 0.92 (95% CI: 0.86, 0.99). Conclusion: iOS accelerometer based assessment of the tremor component of the CIWA-Ar score is reliable and has potential to more accurately assess the severity of patients in alcohol withdrawal. We anticipate this resource will be easily disseminated and will impact and improve the care of patients with alcohol withdrawal.
LO029: Undetected serious medical illness in mental health patients seen in an academic emergency department
Authors: Poss C. , Fernandes C. , Columbus M. , Wood K.
Published: June 2016

Introduction: Mental health concerns make up 5-10% of all adult presentations to Canadian emergency departments (ED). One challenge for the emergency physician (EP) is determining if a patient with a mental health concern has concomitant underlying medical illness. We defined “serious medical illness” (SMI) as a pathological condition that requires inpatient treatment on a medical or surgical ward. SMI undetected by emergency physicians in patients presenting with mental health concerns may result in adverse patient outcomes. The aim of this study was to determine the prevalence, timing, and etiology of undetected SMI in the ED among adult patients presenting with mental health concerns. Methods: A retrospective chart review was performed on all patients age 18 and older who presented to the ED at Victoria Hospital, London Health Sciences Centre between October 1, 2014 and April 30, 2015, who were subsequently referred to psychiatry by the EP. The primary outcome was the number of patients transferred to a medicine or surgery inpatient unit for treatment of their SMI within seven days of psychiatry admission from the ED. Results: 1,255 patients were referred to psychiatry during the study period. 803 patients were admitted and 452 were discharged. Of the admitted patients, 14/803 patients (1.7%) met our primary outcome. The mean age of patients in the SMI group (n=14) was 64 years. The mean age in the non-SMI group (n=1,241) was 38. In the SMI group, 3/14 patients died, 2/14 patients required an ICU admission, and 2/14 patients underwent a surgery for their missed SMI. The average length of psychiatry admission prior to transfer was 3.7 days. The average length of medical/surgical admission after transfer from psychiatry was 8.3 days. Undetected diagnoses included NSTEMI, serotonin syndrome, lithium toxicity, thoracic aortic aneurysm, gastrointestinal stromal tumour, forearm abscess, Parkinsonian crisis, and others. Conclusion: This chart review demonstrated a 1.7% rate of undetected serious medical illness in patients who presented to the ED with mental health concerns. Adverse outcomes included death, ICU admissions, and surgeries. This rate is similar to other studies on the topic. The SMI group tended to be older than the non-SMI group. This research may have implications on the appropriate workup and disposition of elderly patients presenting to the ED with mental health concerns.
LO031: The epidemiology of emergency department visits for dog-related injuries in Alberta
Authors: Jelinski S.E. , Phillips C. , Doehler M. , Rock M. , Checkley S. , Rowe B.H.
Published: June 2016

Introduction: Injuries due to interactions with dogs (e.g. bites, collisions, etc) are an important public health concern from both a health and an economic perspective. The consequences of these injuries can be both physical (injury, pain, infection, disfiguration) and psychological. The purpose of this study is to understand the prevalence and characteristics of dog-related injuries among patients presenting to Alberta emergency departments (EDs). Further, this study describes the burden of these injuries on ED economic health care resources. Methods: This retrospective, administrative database cohort study utilised the National Ambulatory Care Reporting System (NACRS) to identify all visits made to Alberta EDs in fiscal years 2010/11 through 2014/15 for dog-related injuries. ED visits where the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) code “W54-Bitten or Struck by Dog” appeared in the first four diagnosis fields were captured. The Canadian Institute for Health Information costing model utilising the Comprehensive Ambulatory Classification System and Resource Intensity Weights was employed to calculate average unit health care costs for ED visits excluding physician fees. Data were analyzed using descriptive statistics. Results: During the 5 year study period, Albertans made 21,821 ED visits for dog-related injuries. The ED visit rate was highest in children under 2 years of age, namely 234 per 100,000 for males and 206 per 100,000 for females. ED visit rates were highest for patients residing in the northern health region of the province (220/100,000) compared to metropolitan areas (90/100,000 and 64/100,000 for Edmonton and Calgary zones respectively). One third of visits occurred in the summer months, with a greater proportion of visits occurring on the weekend (34.4%). The predominant areas of injury were wrist/hand/fingers (n=7756 visits; 35.5%) and head/face/neck (n=5152 visits; 23.6%). In 287 visits (1.3%), the patient was admitted to hospital. ED visit costs were highest for children 4 years of age and younger ($243.86/visit; p<0.001). Conclusion: Dog-related injuries result in a substantial number of ED visits and significant costs in Alberta. Understanding the characteristics of these injuries provides an opportunity for prevention, including strategies focussed on higher risk groups involving children and residents of rural areas.
LO032: Use of pharmacological sleep aids among emergency medicine staff physicians in a Canadian tertiary-care setting: a web based survey
Authors: Francis M.N. , Iverach R. , Wishart I.M.
Published: June 2016

Introduction: Emergency medicine by its nature requires shift-work that often follows an erratic and unpredictable pattern. Faced with this ongoing challenge we hypothesized that many ED physicians may have taken steps to minimize their personal sleep deprivation through the use of a pharmacological sleep aid (PSA). The extent and nature of PSA use in this population is not well studied. We sought to describe the use of PSAs amongst practicing ED physicians in a Canadian tertiary-care setting. We also hoped to determine the specific substances being used, their frequency and predictive factors contributing to their use. Methods: A cross-sectional descriptive web-based survey was sent via e-mail to all practicing staff emergency physicians within the Calgary zone of Alberta Health Services. Participation was entirely voluntary and all responses were anonymous. Descriptive statistics were used to assess frequencies and summary measures. Logistic regression was used to explore associations between key variables. Results: Of the 198 eligible ED physicians, 144 (73%) completed the survey. 132 (92%) felt that shift-work negatively affected their ability to sleep and 121(84%) had experienced insomnia at some point in their medical career. 96(67%) ED physicians had used a PSA at some time in their career and 82(57%) were currently using a PSA with any frequency. The most frequent sleep aids currently being used were non-benzodiazepine hypnotics (65%), alcohol (31%) and melatonin (27%). 66(46%) respondents required a prescription for their PSA and 37(56%) of those had obtained a prescription from an ED physician colleague. Physician self-reporting of experience with insomnia was strongly associated with prior use of any PSA (OR 4.0; 95% CI 1.6-10.0) and prior use of non-benzodiazepine hypnotics (OR 14.4; 95% CI 3.2-64.2) There was no statistically significant association between current use of a PSA and physician age, physician gender, number of night shifts worked per month or co-habitation with children. None of the physicians who responded felt that their use of a PSA adversely affected their ability to provide quality patient care. Conclusion: Pharmacological sleep aid use among Canadian ED physicians may be more common than previously assumed. This could have implications for physician wellbeing and performance.
LO033: Attitudes of emergency physicians towards homeless and substance using patients
Authors: Nicol J.J. , Dowling S. , Crawford S. , Chow J.G. , Dong K.
Published: June 2016

Introduction: Patients who are homeless and/or using substances rely heavily on emergency departments (ED) for medical care, and present with complex medical and social needs. Negative physician attitudes towards this population undermine the therapeutic relationship, compromising the quality of medical care provided. The objective of this study was to determine the attitudes of emergency physicians towards homeless and substance-using patients. Methods: Using a Modified Total Design approach, we conducted a cross-sectional survey of emergency physicians at five different healthcare locations in Calgary, Alberta, Canada. Attitudes were assessed using two validated measures, the Health Care Providers Attitudes Towards the Homeless Inventory (HPATHI), and the Short Understanding of Substance Use Scale (SUSS). Surveys were self-administered by respondents between March and December 2013. Results: A total of 117 physicians completed the survey (response rate 48%). 28% of respondents resented the amount of time it takes to see homeless patients, and 32% believed caring for homeless patients was not financially viable; 57% felt overwhelmed by the complexity of problems that homeless people have. Physicians with extra training in addiction medicine or health care for the homeless had more positive attitudes than physicians with no extra training; physician attitudes worsened over time towards both populations. Conclusion: Physicians feel overwhelmed when caring for patients who are homeless and/or substance using and negative attitudes worsened over time. Extra training in addiction medicine or healthcare for the homeless is associated with more positive attitudes. Possible strategies to improve attitudes should include a multifaceted approach addressing individual physician knowledge deficits, as well as expanded access to resources in the ED and community, designed to deal with the complex needs of these populations.
LO044: Stress-testing the resuscitation room: latent threats to patient safety identified during interprofessional in-situ simulation in the emergency department
Authors: Mastoras G. , Poulin C. , Norman L. , Weitzman B. , Pozgay A. , Frank J.R.
Published: June 2016

Introduction: Emergency Department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend upon effective interactions between the healthcare team, the patient, and the environment. To this end, resuscitation teams work in spaces designed to optimize workflows and ensure that necessary treatments and skillsets are available when required. However, systematic failures in this environment cannot always be adequately anticipated, exposing patients to opportunities for harm. As part of a new interprofessional education initiative, this prospective, observational study sought to characterize latent threats to patient safety (LST’s) identified during the delivery of in-situ, simulated resuscitations in two Canadian, tertiary care, academic Emergency Departments. Methods: In-situ simulation sessions were delivered on a monthly basis in the EDs of each hospital campus, during which a variety of simulated resuscitation scenarios were run with distinct teams of ED healthcare professionals. A research assistant was present throughout each session and documented LST’s identified by simulation facilitators and participants during the case and debriefing. Data were entered into a master table and grouped thematically for analysis. Results: After a pilot run-in, 10 in-situ simulation sessions were delivered, involving 27 cases and reaching 180 ED healthcare professionals (25 attending MD, 37 resident MD, 59 RN, 24 RT). 83 latent safety threats were identified through these sessions (mean 3.1 LSTs per case) of which 52 were determined to be “actionable”. Corrective mechanisms have been initiated in 72% of these cases (e.g., new education campaigns and in-servicing, equipment provisioning, equipment checklists). Conclusion: In-situ simulation, beyond its role as a training tool for developing Non-Technical and Crisis Resource Management skills, can be effectively used to identify systematic deficits and knowledge gaps that could expose critically ill patients to harm. Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care.
LO046: Factors associated with hospital admission following asthma exacerbations: a systematic review
Authors: Rowe B.H. , Arrotta N. , Hill J. , Dennett E. , Harries M.
Published: June 2016

Introduction: Patients with asthma frequently present to the emergency department (ED) with exacerbations; however, a select number of patients require admission to hospital. The objective of this study was to summarize the evidence regarding asthma-related hospital admissions and factors associated with these admissions following ED presentation. Methods: Comprehensive literature searches were conducted in seven electronic databases (database inception to 2015); manual and grey literature searches were also performed. Studies reporting disposition for adults after ED presentation were included. Study quality was assessed using the Newcastle-Ottawa Scale (NOS); standardized data-collection forms were used for data extraction. Admission proportions and factors associated with admission at a statistical significance level (p<0.05) were reported. Results: Out of an initial 5865 identified articles, 37 articles met full inclusion criteria. Admission proportions were reported in 25/37 studies, ranged from 1% to 37%, and collectively demonstrated a decline of ~9% in admissions between 1993 and 2012. Studies including a >50% Caucasian ethnicity were found to have a median admission proportion of 13% (interquartile range [IQR]= 7, 20) versus studies with >50% non-Caucasian ethnicity at 22% (IQR=20, 28). Age, female sex, and previous hospitalizations for asthma exacerbation were the most individually identifiable factors associated with admission. Presenting features and medication profile were the most frequent domains associated with admission. Conclusion: Admission rates have decreased approximately 9% in a nearly 20-year span and seem to be higher in studies involving mostly non-Caucasian ethnic groups. Demographic factors, markers of severity obtained by history or at ED presentation, and medication profile could be assessed by ED clinicians to effectively discern patients at high risk for admission.
LO047: Predictors of treatment failure in renal colic patients discharged from the emergency department
Authors: Innes G. , Andruchow J. , McRae A. , Junghans T. , Lang E.
Published: June 2016

Introduction: Most patients with acute renal colic are discharged from the ED after initial diagnosis and symptom control, but 20-30% require repeat ED visits for ongoing pain, and 15-25% require rescue intervention (ureteroscopic intervention or lithotripsy). If patients destined for failure of outpatient management could be identified based on information available during their ED visits, they could be prioritized early for intervention to reduce short term pain and disability. Our objective was to identify predictors of outpatient treatment failure, defined as the need for hospitalization or rescue intervention within 60 days of ED discharge. Methods: We collated prospectively gathered administrative data from all Calgary region patients with an ED diagnosis of renal colic over a one-year period. Demographics, arrival mode, triage category, vital signs, pain scores, analgesic use and ED disposition were recorded. Research assistants reviewed imaging reports and documented stone characteristics. These data were linked with regional hospital databases to identify ED revisits, hospital admissions, and surgical procedures. The primary outcome was hospitalization or rescue intervention within 60 days of ED discharge. Results: Of 3104 patients with first ED visit for acute renal colic, 1296 had CT or US imaging and were discharged without intervention. Median age was 50 years and 69% were male. 325 patients (25.1%) required an ED re-visit and 11.8% required admission or rescue intervention. Patients with small (<5mm), medium (5-7mm) and large (>7mm) stones failed in 9.0%, 14.4% and 9.9% of cases respectively. The only factor predictive of treatment failure in multivariable models was stone position in the proximal or mid-ureter. Age, sex, vital signs, pain score, WBC, creatinine, history of prior stone or intervention, stone side, stone size, presence of stranding and degree of hydronephrosis were not associated with outpatient failure. Conclusion: Outpatient treatment failure could not be predicted based on any of the predictors studied.