bluuebunny/crossref_metadata_2025 huggingface dataset:
P126: Utilization and outcomes of children presenting to an emergency department by ambulance
Authors: Cantor Z. , Aglipay M. , Plint A.
Published: May 2020

Introduction: Children account for a low proportion of paramedic transports. Evidence suggests that many pediatric transports are of low acuity, but there are few studies comparing these patients to those that self-present to the ED. Our primary objective was to determine if illness severity was associated with presentation by ambulance among pediatric patients. Methods: We undertook a single centre, retrospective cohort study at a tertiary care pediatric centre. All patients presenting to the ED in 2015 by any route other than air ambulance were eligible. Patients were divided into two groups based on the route of presentation – ambulance or self-presentation. The primary outcome was disposition decision; the secondary outcome was CTAS level. To determine whether patient discharge disposition or CTAS was associated with the method of arrival, we conducted generalized estimating equations (GEE) to account for correlation within patients with multiple ED visits. Results: Of the 69,092 visits, 69,034 were eligible and analyzed. Of those, 4478 (6.5%) arrived by ambulance, while 64,556 (93.5) self-presented. Those arriving by ambulance had a median age of 10 years [IQR: 2-5 years] vs. 4 years [IQR: 1.75-10 years] in the self-presenting group and were 52.6% male (vs. 52.8%). Two percent of the ambulance cohort were admitted to the ICU (vs. 0.2%), and 16.6% were admitted to the ward (vs. 5%). Patients presenting by ambulance had higher CTAS scores – 5.3% CTAS 1 (vs. 0.3%), 16.4% CTAS 2 (vs. 7.0%), 61.2% CTAS 3 (vs. 45.8%), and 17.1% CTAS 4-5 (vs. 46.9%). The odds of arriving by ambulance were 10.2 x higher for patients admitted to the ICU (OR = 10.2, 95%CI: 7.9 to 13.3) vs. those discharged home. The odds of arriving by ambulance were 64.2 x (OR = 64.2, 95% CI: 48.6 to 84.7) higher for patients CTAS 1 patients vs. CTAS 5 patients. The top 3 complaints among ambulance patients were neurological (22.5%), respiratory (22.7%), and orthopaedic (11.3%). Among self-presenting patients, the top three were general/minor (20.4%), respiratory (16.4%), and gastrointestinal (14.3%). Conclusion: Children presenting to the ED via ambulance are at higher risk for admission to the ward and critical care unit. It is important that paramedics have sufficient training to ensure adequate skills to manage critically ill children. Given the low proportion but higher severity of illness of pediatric transports, further research and consideration must be given to how best to enable paramedics in the management of children.
P133: A novel addictions curriculum for emergency medicine residents
Authors: Bérczi B. , Chan K.
Published: May 2020

Innovation Concept: In the era of the current opioid crisis, addiction medicine is becoming a core competency of patient care. Despite the prevalence of addiction-related presentations, there is a paucity of formal education on the topic in emergency medicine; with time and lack of qualified staff cited as barriers to implementation. We aimed to correct this gap in education through the curriculum design of an addictions elective that can be easily implemented by Emergency Medicine Program Directors across Canada. Methods: Learning objectives were developed based on expert consensus and the list of entrustable professional activities (EPAs) mandated by the Royal College. A local needs assessment was conducted to identify existing addictions curriculum and identify opportunities for improvement. Curriculum, Tool, or Material: A one-month block addictions selective was developed specifically for emergency medicine residents. Elements of this curriculum included a suggested schedule, a list of supplemental resources, and an evaluation tool to track EPAs. A pre and post survey was created for distribution to all participants to track knowledge acquisition and to collect feedback on the education intervention. In the 2019-2020 academic year, 4 residents participated in this selective and multiple have expressed interest for the future. Conclusion: In Ontario alone, the rate of opioid-related deaths has quadrupled and has escalated to a rate of 2 deaths every day. Alcohol and other substance use is commonly a chief concern, catalyst, or comorbidity for patient presentations in the emergency department. Our selective curriculum seeks to address a gap for emergency medicine residents. Ongoing program evaluation will take place to continue to optimize this learning experience.
P140: Variability in practice patterns in the emergency department treatment of hyperkalemia
Authors: Alaraimi R. , Gosselin S. , Clark G. , Gangatharan H. , Tam R. , Villeneuve E. , Meyers C. , Iannuzzi D. , Grunbaum A.
Published: May 2020

Introduction: Hyperkalemia is a common electrolyte disturbance associated with morbidity and mortality. Commonly used therapies for hyperkalemia include IV calcium, sodium bicarbonate, insulin, beta-adrenergic agents, ion-exchange resins, diuretics and hemodialysis. This study aims to evaluate which treatments are more commonly used to treat hyperkalemia and to examine factors which influence those clinical decisions. Methods: This is a retrospective chart review of all cases of hyperkalemia encountered in 2017 at a Canadian adult ED. Potassium values were classified as mild (5.5 - 6.5 mEq/L), moderate (>6.5 - 7.5 mEq/L) and severe (>7.5 mEq/L). Treatment choices were then recorded and matched to hemodynamic stability, degree of hyperkalemia and ECG findings. More statistical methods to test correlation between treatment and specific variables will be performed over the next 2 months, including logistic regression to highlight potential determinants of treatment and Chi-square tests to verify randomness and to construct 95% confidence intervals. Results: 1867 ED visits were identified, of which 479 met the inclusion criteria. 89.1% of hyperkalemia cases were mild, 8.2% were moderate, and 2.7% were severe. IV insulin was used in 22.1% of cases, followed by Kayexalate in 20.5%, sodium bicarbonate in 12.3%, IV calcium in 9.4%, frusemide in 7.3%, salbutamol in 2.7%, and dialysis in 1.9%. Moderate and severe hyperkalemia were associated with higher use of insulin (79.5% and 64.3% respectively), IV calcium (41% and 64.3% respectively), sodium bicarbonate (56.4% and 85.7% respectively). Bradycardia was associated with higher insulin and IV calcium use (46.7% and 33.3% respectively). Hypotension was associated with a similar increase in use of insulin and IV calcium (34.2% and 23.7% respectively). There were only 15 cases of cardiac arrest in which sodium bicarbonate and IV calcium were more frequently used (80% and 60% respectively). Conclusion: This study demonstrates variability in the ED management of hyperkalemia. We found that Insulin and Kayexalate were the 2 most common interventions, with degree of hyperkalemia, bradycardia and hypotension influencing rates of treatment. Overuse of kayexalate for emergent treatment of hyperkalemia is evident despite weak supporting evidence. Paradoxically, beta adrenergic agents were underutilized despite their rapid effect and safer profile. The development of a widely accepted guideline may help narrow the differences in practice and potentially improve outcomes.
Regional needs assessment for emergency physician audit and feedback
Authors: Gupta Rakesh , Mercuri Mathew , McCulloch Amy , Monteiro Sandra , Mastoras George , Krywenky Ashley , Chan Teresa , Mondoux Shawn
Published: May 2020

Objectives

Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region.

Methods

We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups.

Results

A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners.

Conclusion

This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.
Just the Facts: What are the roles of oxygen escalation and noninvasive ventilation in COVID-19?
Authors: Long Brit , Liang Stephen Y. , Hicks Christopher , Gottlieb Michael
Published: May 2020

A 37-year-old female presents with cough, fever, dyspnea, and myalgias for five days after recent contact with a family member with confirmed 2019 coronavirus disease (COVID-19). Her vital signs include T 38.3° C, HR 108, BP 118/70 mm Hg, RR 26 breaths per minute, and oxygen saturation 67% on room air. She is not in respiratory distress currently and is protecting her airway. Her chest X-ray reveals bilateral airspace opacities. You plan to immediately intervene and address her hypoxia.
PL02: Double Sequential External Defibrillation for Refractory Ventricular Fibrillation: the DOSE VF pilot randomized controlled trial
Authors: Cheskes S. , Dorian P. , Feldman M. , McLeod S. , Scales D. , Pinto R. , Turner L. , Morrison L. , Drennan I. , Verbeek P.
Published: May 2020

Introduction: Despite recent advances in resuscitation, some patients remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Vector change defibrillation (VC) and double sequential external defibrillation (DSED) have been proposed as alternate therapeutic strategies for OHCA patients with refractory VF. The primary objective was to determine the feasibility, safety and sample size required for a future cluster randomized controlled trial (RCT) with crossover comparing VC or DSED to standard defibrillation for patients experiencing refractory VF. Secondary objectives were to evaluate the intervention effect on VF termination and return of spontaneous circulation (ROSC). Methods: We conducted a pilot cluster RCT with crossover in four Canadian paramedic services and included all treated adult OHCA patients who presented in VF and received a minimum of three defibrillation attempts. In addition to standard cardiac arrest care, each EMS service was randomly assigned to provide continued standard defibrillation (control), VC or DSED. Services crossed over to an alternate defibrillation strategy after six months. Prior to the launch of the trial, 2,500 paramedics received in-person training for VC and DSED defibrillation using a combination of didactic, video and simulated scenarios. Results: Between March 2018 and September 2019, 152 patients were enrolled. Monthly enrollment varied from 1.4 to 6.1 cases per service. With respect to feasibility, 89.5% of cases received the defibrillation strategy they were randomly allocated to, and 93.1% of cases received a VC or DSED shock prior to the sixth defibrillation attempt. There were no reported cases of defibrillator malfunction, skin burns, difficulty with pad placement or concerns expressed by paramedics, patients, families, or ED staff about the trial. In the standard defibrillation group, 66.6% of cases resulted in VF termination, compared to 82.0% in VC and 76.3% of cases in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively. Conclusion: Findings from our pilot RCT suggest the DOSE VF protocol is feasible and safe. VF termination and ROSC were higher with VC and DSED compared to standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact patient-centered, clinical outcomes
LO17: Major adverse cardiac events in patients ruled-out by a validated high-sensitivity troponin algorithm for acute myocardial infarction
Authors: O'Rielly C. , Andruchow J. , McRae A.
Published: May 2020

Introduction: Chest pain and symptoms of acute coronary syndrome are a leading cause of emergency department (ED) visits in Canada. Validated 2-hour high-sensitivity troponin algorithms can rapidly and accurately rule-in or rule-out myocardial infarction (MI) in most patients. The objective of this study was to quantify the incidence and timing of major adverse cardiac events (MACE: MI, death, or urgent revascularization) in the 30-days following the index ED encounter among patients who had MI ruled out using a 2-hour high-sensitivity troponin T (hs-cTnT) algorithm. We also sought to identify patient characteristics associated with very low risk of MACE. Methods: This was a secondary analysis of data prospectively collected from adult patients presenting with a primary complaint of chest pain or symptoms of ACS. This analysis focused on patients who had an MI ruled out using a validated 2-hour serial hs-cTnT diagnostic algorithm. Incidence of 30-day MACE was quantified. Sex-specific Kaplan-Meier curves were constructed to describe timing of MACE events after MI rule-out. Demographic and clinical variables of patients who did or did not have MACE were compared using simple bivariable analyses. Results: This analysis included 550 patients with serial 2h hs-cTnT testing. Of these, MI was ruled out in 344 (62.5% of patients), ruled in 67 (12.2%), and 139 (25.3%) had nondiagnostic hs-cTnT results. Among the 344 patients who had MI ruled out, 11 (3.2%) experienced a MACE in the 30 days following their index ED encounter. These included 10 (2.9%) unplanned revascularizations and 1 (0.3%) fatal MI. MACE occurred at a median of 5 days (range: 0-23 days) after the index ED encounter. Of the 11 patients experiencing MACE, 9 (81.8%) had a normal ECG at their index ED encounter. None of the 93 (27.0%) ruled-out patients under the age of 50 experienced a MACE in the follow-up period. Patients experiencing MACE were more likely to have a history of coronary disease and multiple vascular risk factors compared to those not experiencing MACE. Conclusion: The validated 2h hs-cTnT AMI algorithm ruled-out MI in a large proportion of patients. The 30-day MACE incidence after MI rule-out was 3%. Most MACE events were unplanned revascularizations. We determined that age < 50 was associated with event-free survival and may be of value in identifying patients who do not need additional cardiac testing after MI has been ruled out using high-sensitivity troponin testing.
LO20: The characteristics, clinical course and disposition of long-term care patients treated by paramedics during an emergency call: Exploring the potential impact of community paramedicine
Authors: Leduc S. , Wells G. , Thiruganasambandamoorthy V. , Cantor Z. , Kelly P. , Rietschlin M. , Vaillancourt C.
Published: May 2020

Introduction: An increasing number of Canadian paramedic services are creating Community Paramedic programs targeting treatment of long-term care (LTC) patients on-site. We explored the characteristics, clinical course and disposition of LTC patients cared for by paramedics during an emergency call, and the possible impact of Community Paramedic programs. Methods: We completed a health records review of paramedic call reports and emergency department (ED) records between April 1, 2016 and March 31, 2017. We utilized paramedic dispatch data to identify emergency calls originating from LTC centers resulting in transport to one of the two EDs of the Ottawa Hospital. We excluded patients with absent vital signs, a Canadian Triage and Acuity Scale (CTAS) score of 1, and whose transfer to hospital were deferrable or scheduled. We stratified remaining cases by month and selected cases using a random number generator to meet our apriori sample size. We collected data using a piloted standardized form. We used descriptive statistics and categorized patients into groups based on the ED care received and if the treatment received fit into current paramedic medical directives. Results: Characteristics of the 381 included patients were mean age 82.5 years, 58.5% female, 59.7% hypertension, 52.6% dementia and 52.1% cardiovascular disease. On arrival at hospital, 57.7% of patients waited in offload delay for a median time of 45 minutes (IQR 33.5-78.0). We could identify 4 groups: 1) Patients requiring no treatment or diagnostics in the ED (7.9%); 2) Patients receiving ED treatment within current paramedic medical directives and no diagnostics (3.2%); 3) Patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and 4) patients requiring admission (34.1%). Most patients were discharged from the ED (65.6%), and 1.1% died. The main ED diagnoses were infection (18.6%) and musculoskeletal injury (17.9%). Of the patients that required ED care but were discharged, 64.1% required x-rays, 42.1% CT, and 3.4% ultrasound. ED care included intravenous fluids (35.7%), medication (67.5%), antibiotics (29.4%), non-opioid analgesics (29.4%) and opioids (20.7%). Overall, 11.1% of patients didn't need management beyond current paramedic capabilities. Conclusion: Many LTC patients could receive care by paramedics on-site within current medical directives and avoid a transfer to the ED. This group could potentially grow using Community Paramedics with an expanded scope of practice.
LO28: Innovating for overcrowding: analyzing the impact of a novel emergency physician role on patient flow
Authors: Green-Harrison L. , Polsky Z. , Fung T. , Lang E. , Patocka C.
Published: May 2020

Introduction: Overcrowding in the Emergency Department (ED) results in delays in care, and increased patient morbidity and mortality. Innovative departmental approaches have the potential to make patient flow through the ED more efficient and reduce overcrowding by improving patient throughput. The Calgary zone ED recently piloted a new physician role, the Emergency Physician Lead (EPL), a senior physician working closely with the charge nurse and consulting services to provide physician leadership, and to troubleshoot flow issues and safety breeches such as EMS offload delays and long emergency inpatient (EIP) stays. The objective of this study was to evaluate the efficacy of the EPL by determining its effect on key metrics of patient flow, and by identifying which specific EPL interventions were most effective at improving patient throughput. Methods: A retrospective cohort design was used to compare Foothills Medical Centre (FMC) ED patients seen by the EPL from March-June 2019 (n = 1343 patients) with a control group from the same period in 2018 (n = 5530). An EMR search was used to collect patient data and generate descriptive statistics, which were compared between groups by Mann-Whitney U-test. Patient handover notes left by the EPL were also collected and analyzed by two independent assessors to develop a list of actions taken by the EPL. Each patient was then coded based on the actions in the handover note, and means for each coded group were compared to control to find correlations between action and changes in key flow metrics. Results: Patients whose care involved the EPL had a 40% shorter average ED length of stay (ELOS) compared to control (515 vs 865 min, p < 0.001). The EPL was especially effective for patients with ELOS above the 90th percentile, with a 58% relative reduction. EPL patients also had lower average times from first contact with the department to first order being placed (79 vs 143 min, p < 0.001), and spent less time as EIPs after being admitted (390 vs 515 mins, p < 0.001). EPL actions aimed at early ordering of investigations or early management showed the largest relative reductions in ELOS, followed by actions related to resolving issues with consulting services (56% and 48% respectively, p < 0.001). Conclusion: The EPL role appears to be associated with improvements in several key metrics of patient flow. Specific EPL actions were correlated with marked decreases in length of stay. The EPL may be an effective strategy to improve patient throughput and combat ED overcrowding.
LO29: Interventions at triage to improve emergency department throughput: a systematic review
Authors: Grant K. , Bayley C. , Lang E. , Innes G.
Published: May 2020

Introduction: Emergency Department (ED) crowding is the primary threat to emergency care quality. Input and outflow factors are important factors, but EDs must optimize throughput efficiency by improving internal processes from triage to disposition, and triage is the first throughput phase. Triage throughput interventions exclude strategies that direct patients away from the ED (these modify input rather than throughput). Previous research has described physicians in triage, team triage, telemedical triage, and nurse practitioner (NP) or physician assistant (PA) led triage, but their impact has never been systematically evaluated. Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without the use of filters or language restrictions of all triage interventions that effected ED throughput (PROSPERO:CRD42019125651). Two independent reviewers screened studies. Study quality was assessed using the Cochrane Risk of Bias tool (version 2) for randomized controlled trials, and the National Heart, Lung, and Blood Institute quality assessment tool for other designs. Results: 18 studies met inclusion criteria (Cohen's k = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. Studies were grouped into physician led, NP or PA led, and team triage interventions. Six physician in triage interventions reported LOS changes between -82 and + 18 minutes. Five NP/PA led triage interventions resulted in LOS changes of -106 to + 19 minutes. Five team triage interventions reported LOS reductions of 4 to 34 minutes. One telemedicine triage study reported a non-significant 8 minute increase in LOS. Six physician at triage interventions yielded significant LWBS rate improvement (relative risk {RR}= 0.29-0.82). Team triage interventions generated LWBS rate changes ranging from meaningful improvement (RR = 0.58) to substantial deterioration (RR = 1.68). Five studies have low risk of bias, 11 studies have some risk of bias, and 2 studies have high risk of bias (Cohen's kappa = 0.58). Conclusion: Fourteen of 18 triage interventions reduced EDLOS and/or LWBS rate. Physician, NP and PA led triage were the most effective triage interventions. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.
LO35: A province-wide quality improvement collaborative for treatment of children's pain in Alberta's emergency departments
Authors: Thull-Freedman J. , Pols E. , McFetridge A. , Libbey S. , Lonergan K. , Lethebe B. , Ali S. , Stang A.
Published: May 2020

Background: Pediatric pain is often under-treated in emergency departments (EDs), causing short and long-term harm. In Alberta EDs, children's pain outcomes were unknown. A recent quality improvement collaborative (QIC) led by our team improved children's pain care in 4 urban EDs. We then spread to all EDs in Alberta using the Institute for Healthcare Improvement Framework for Going to Full Scale. Aim Statement: To increase the proportion of children <12 years who receive topical anesthetic before needle procedures from 11% to 50%; and for children <17 years with fractures: to 1) increase the proportion receiving analgesia from 31% to 50%; 2) increase the proportion with pain score documentation from 24% to 50%, and 3) reduce time to analgesia from 60 to 30 minutes, within 1 year. Measures & Design: All 97 EDs in Alberta that treat children were invited. Each was asked to form a project team, attend webinars, develop key driver diagrams and perform PDSA tests of change. Sites were given a monthly list of randomly selected charts for audit and entered data in REDCap for upload to a provincial run chart dashboard. Baseline performance measurement informed aims. Measures included proportion of children <12 years undergoing a lab test who received topical anesthetic, and for children <17 years with fracture, the proportion with a pain score, proportion receiving analgesia and median minutes to analgesia. Length of stay and use of opioids were balancing measures. Control charts were used to detect special cause. Interrupted time series (ITS) was performed to assess significance and trends. Evaluation/Results: 36 sites (37%) participated, including rural and urban sites from all regions. 8417 visits were audited. 23/36 sites completed audits before and after tests of change and were analyzed. Special cause occurred for all aims. The proportion receiving topical anesthetic increased from 11% to 30% (ITS p < 0. 001). For children with fractures, the proportion with pain scores increased from 24% to 34% (ITS p = 0.21, underlying trend present), proportion receiving analgesic medication increased from 31% to 39% (ITS p = 0.41, underlying trend present) and minutes to analgesia decreased from 60 to 28 (ITS p < 0. 01). There was no increase in length of stay or use of opioid medications. Discussion/Impact: A pragmatic approach encouraging locally led change was well-received and key to success. The QIC method shows promise for improving outcomes in diverse EDs across large geographic areas. Next steps include further spread and sustainability measurement.
LO37: Reducing hemolysis of coagulation blood samples in the emergency department
Authors: Weatherby H. , Woolner V. , Chartier L. , Casey S. , Ong C. , Gaylord E.
Published: May 2020

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.
LO39: Using an ambulatory zone to improve physician initial assessment times in a tertiary care hospital emergency department
Authors: Verma A. , Cheng I. , Pardhan K. , Notario L. , Thomas-Boaz W. , Shelton D.
Published: May 2020

Background: Increasing Emergency Department (ED) stretcher occupancy with admitted patients at our tertiary care hospital has contributed to long Physician Initial Assessment (PIA) times. As of Oct 2019, median PIA was 2.3 hours and 90th percentile PIA was 5.3 hours, with a consequent 71/74 PIA ranking compared to all Ontario EDs. Ambulatory zone (AZ) models are more commonly used in community EDs compared to tertiary level EDs. An interdisciplinary team trialled an AZ model for five days in our ED to improve PIA times. Aim Statement: We sought to decrease the median PIA for patients in our ED during the AZ trial period as compared to days with similar occupancy and volume. Measures & Design: The AZ was reserved for patients who could walk from a chair to stretcher. In this zone, ED rooms with stretchers were for patient assessment only; when waiting for results or receiving treatment, patients were moved into chairs. We removed nursing assignment ratios to increase patient flow. Our outcome measure was the median PIA for all patients in our ED. Our balancing measure was the 90th percentile PIA, which could increase if we negatively impacted patients who require stretchers. The median and 90th percentile PIA during the AZ trial were compared to similar occupancy and volume days without the AZ. Additional measures included ED Length of Stay (LOS) for non-admitted patients, and patients who leave without being seen (LWBS). Clinicians and patients provided qualitative feedback through surveys. Evaluation/Results: The median PIA during the AZ trial was 1.5 hours, compared to 2.1 hours during control days. Our balancing measure, the 90th percentile PIA was 3.7 hours, compared to 5.0 during control days. A run chart revealed both median and 90th percentile PIA during the trial were at their lowest points over the past 18 months. The number of LWBS patients decreased during the trial; EDLOS did not change. The majority of patients, nurses, and physicians felt the trial could be implemented permanently. Discussion/Impact: Although our highly specialized tertiary care hospital faces unique challenges and high occupancy pressures, a community-hospital style AZ model was successful in improving PIA. Shorter PIA times can improve other quality metrics, such as timeliness of analgesia and antibiotics. We are working to optimize the model based on feedback before we cycle another trial. Our findings suggest that other tertiary care EDs should consider similar AZ models.
Kicking the Crusaders out of the Caucasus: Deconstructing the 200-Year-Old Meme that the Khevsurs Descended from a Lost Band of Medieval Knights
Authors: Sherman Ryan Michael
Published: May 2020

The region of Khevsureti in Georgia is the historic home of a group of Kartvelian highlanders known as Khevsurs. As Khevsureti’s popularity as a mountain tourist destination has grown, so too has the popularity of an old story that asserts the Khevsurs are the descendants of a lost band of Crusaders. For 200 years, this meme has manifested itself in books about the region, newspaper articles, the work of a few scholars, and now much Internet discussion. The growing collection of cases has created the illusion of an unconsolidated quantity of evidence and many commentators have since taken the story to be a credible theory or actual legend. A systematic deconstruction and analysis of this story shows how this set of details initially formed, grew, and spread based on a few unreliable accounts in circulation beginning in the early 19th century. This article offers a case study of how such memes form and propagate; it provides an additional example of a Western tendency to romanticize and project elements of their own ethnicities into the Caucasus; and it examines this false history in terms of cultural appropriation and the relationship between ethnicity and narrative, adding to the literature on invented histories and pseudoarchaeology. Finally, this careful deconstruction and repudiation will help remove this story from serious discussions of cultural heritage in Khevsureti and show how historical memes and popular examples of pseudoarcheology spread and capture imaginations.
The Don and Kuban Regions During Famine: The Authorities, the Cossacks, and the Church in 1921–1922 and 1932–1933
Authors: Krinko Evgeny , Skorik Alexander , Shadrina Alla
Published: May 2020

This article studies the famine of 1921–1922 and 1932–1933 in the Southern Russian regions. Famine as a socio-historical phenomenon is considered in the context of the relationship of state power, the Cossacks, and the Church. The authors reveal the general and special features of the famine emergence and analyze the differences in the state policies of 1921–1922 and 1932–1933. Considerable attention is paid to the survival strategies of the Don, Kuban and Terek populations. Slaughtering and eating draft animals, transfer from the state places of work to the private campaigns and cooperatives, moving to shores and banks, and eating river and sea food became widespread methods of overcoming famine. Asocial survival strategies included cannibalism, abuse of powers, bribery, and more. In 1921–1922, the Russian Orthodox Church fought actively against the famine. In 1932–1933, the Church was weakened and could not provide significant assistance to the starving population. The article was written based on declassified documents from the state and departmental archives, including criminal investigations and analytical materials of the Obedinjonnoe gosudarstvennoe politicheskoe upravlenie [Joint State Political Directorate] (OGPU) recording the attitudes of minds. Also used are personal stories—namely, interviews with eyewitnesses of the famine of 1932–1933, recorded by the Kuban folklorists in the territory of the Krasnodar and Stavropol Krai.
A new method for quantifying heterochrony in evolutionary lineages
Authors: Lamsdell James C.
Published: May 2020

The occupation of new environments by evolutionary lineages is frequently associated with morphological changes. This covariation of ecotype and phenotype is expected due to the process of natural selection, whereby environmental pressures lead to the proliferation of morphological variants that are a better fit for the prevailing abiotic conditions. One primary mechanism by which phenotypic variants are known to arise is through changes in the timing or duration of organismal development resulting in alterations to adult morphology, a process known as heterochrony. While numerous studies have demonstrated heterochronic trends in association with environmental gradients, few have done so within a phylogenetic context. Understanding species interrelationships is necessary to determine whether morphological change is due to heterochronic processes; however, research is hampered by the lack of a quantitative metric with which to assess the degree of heterochronic traits expressed within and among species. Here I present a new metric for quantifying heterochronic change, expressed as a heterochronic weighting, and apply it to xiphosuran chelicerates within a phylogenetic context to reveal concerted independent heterochronic trends. These trends correlate with shifts in environmental occupation from marine to nonmarine habitats, resulting in a macroevolutionary ratchet. Critically, the distribution of heterochronic weightings among species shows evidence of being influenced by both historical, phylogenetic processes and external ecological pressures. Heterochronic weighting proves to be an effective method to quantify heterochronic trends within a phylogenetic framework and is readily applicable to any group of organisms that have well-defined morphological characteristics, ontogenetic information, and resolved internal relationships.
Sex differences in associations of socioemotional dispositions measured in childhood and adolescence with brain white matter microstructure 12 years later
Authors: Lahey Benjamin B. , Hinton Kendra E. , Meyer Francisco Calvache , Villalta-Gil Victoria , Van Hulle Carol A. , Applegate Brooks , Yang Xiaochan , Zald David H.
Published: May 2020

Predictive associations were estimated between socioemotional dispositions measured at 10–17 years using the Child and Adolescent Dispositions Scale (CADS) and future individual differences in white matter microstructure measured at 22–31 years of age. Participants were 410 twins (48.3% monozygotic) selected for later neuroimaging by oversampling on risk for psychopathology from a representative sample of child and adolescent twins. Controlling for demographic covariates and total intracranial volume (TICV), each CADS disposition (negative emotionality, prosociality, and daring) rated by one of the informants (parent or youth) significantly predicted global fractional anisotropy (FA) averaged across the major white matter tracts in brain in adulthood, but did so through significant interactions with sex after false discovery rate (FDR) correction. In females, each 1 SD difference in greater parent-rated prosociality was associated with 0.43 SD greater FA (p< 0.0008). In males, each 1 SD difference in greater parent-rated daring was associated with 0.24 SD lower FA (p< 0.0008), and each 1 SD difference in greater youth-rated negative emotionality was associated with 0.18 SD greater average FA (p< 0.0040). These findings suggest that CADS dispositions are associated with FA, but associations differ by sex. Exploratory analyses suggest that FA may mediate the associations between dispositions and psychopathology in some cases. These associations over 12 years could reflect enduring brain–behavior associations in spite of transactions with the environment, but could equally reflect processes in which dispositional differences in behavior influence the development of white matter. Future longitudinal studies are needed to resolve the causal nature of these sex-moderated associations.
Clay-fraction strontium and neodymium isotopes in the Indus Fan: implications for sediment transport and provenance
Authors: Carter Samantha C. , Griffith Elizabeth M. , Clift Peter D. , Scher Howie D. , Dellapenna Timothy M.
Published: May 2020

Reconstructing the provenance of siliciclastic marine sediment is important for understanding sediment pathways and constraining palaeoclimate and erosion records. However, physical fractionation of different size fractions can occur during sediment transport, potentially biasing records derived from bulk sediment. In this study, records of radiogenic Sr and Nd isotopic composition and K/Al ratio of the separated clay fraction, as well as bulk grain size, are presented, measured from deep-sea sediments recovered from International Ocean Discovery Program (IODP) Sites U1456 and U1457 in the Arabian Sea. These new records are compared with published bulk sediment records to investigate the influence of sediment transport on these proxies and to constrain provenance evolution and its relationship to climate variability since middle Miocene time. Correlations between grain size and the bulk sediment isotopic composition confirm that transport processes are influencing the bulk sediment record. This relationship, although present, is not as strong in the clay-fraction isotopic records. Heterogeneity of bulk sediment likely drives differences between bulk and clay records, thought to be largely controlled by sediment transport processes. The isotopic records reveal variations in provenance that correlate with climatic change at 8–7 Ma, as well as an increase in overall provenance variability beginning at c. 3.5 Ma, likely linked to monsoon strength and glacial–interglacial cycles. The clay-fraction records highlight the potential value of measuring proxy records from multiple size fractions to help constrain provenance records as well as investigate sediment transport and/or weathering and erosion processes recorded in deep-sea sediment archives.
Short-term responses of soil organic carbon and its labile fractions to different manure Nitrogen input in a double-cropping rice field
Authors: Tang Haiming , Xiao Xiaoping , Li Chao , Pan Xiaochen , Cheng Kaikai , Shi Lihong , Li Weiyan
Published: May 2020

Changes in soil bulk density (BD), soil organic carbon (SOC) content, SOC stocks and soil labile organic C fractions (mineralizable C (Cmin), microbial biomass C (MBC), dissolved organic C (DOC), particulate organic C (POC), light fraction organic C (LFOC) and permanganate oxidizable C (KMnO4-C)) were explored over 3 years in a double-cropping rice system of southern China. Five organic and inorganic nitrogen (N) inputs were used: (1) 100% from chemical fertilizer (M0), (2) 30% from organic manure, 70% from chemical fertilizer (M30), (3) 50% from organic manure, 50% from chemical fertilizer (M50), (4) 100% from organic manure (M100) and (5) without N fertilizer input, as control (CK). All organic manure treatments decreased BD significantly in the 0–20 cm soil layer compared with CK. The SOC content and stocks with organic manure were significantly higher than in M0 or CK; also, the cumulative amount of SOC stocks in M30 and M50 increased at the plough layer, compared with CK. The non-labile C content increased significantly and the percentage of labile C were significantly higher with organic manure application than in M0 or CK. The soil carbon management index (CMI) also increased significantly under the application of organic manure. Therefore, application of organic manure can increase the pool of stable C in surface layers, and increase content and percentage of labile C. Based on soil carbon storage and CMI, the combined application of 30 or 50% N of organic manure with chemical fertilizer improves carbon cycling services and soil quality in southern China paddy soil.
Workshops and World Order Studies
Authors: McCandless Raymond
Published: May 2020

My classroom experience over the past seven years has convinced me that teaching does indeed offer a special opportunity for learning. Obviously this conclusion has been reached by a countless number of instructors who have taken a serious approach to their teaching. A special understanding and confidence in one's knowledge of the subject-matter comes through the preparation and presentation of a course or even a singular class lecture.

I have attempted to provide undergraduate students with the opportunity for this type of learning experience. A method employed by many instructors is to have students present research projects/papers in class. Although this exercise does approximate the teaching experience, many times the session degenerates into the mere reading of a prepared research paper.
Introducing Students to Locke and Madison
Authors: Olufs Dick W.
Published: May 2020

The first half of my Introduction to Political Science course deals with normative theory, in particular the theories underlying the American method of organizing a polity. I agree with C.B. MacPherson that Locke's Second Treatise provided the “title deeds” of the liberal state and is a crucial part of American thinking on politics, the individual, and the state. Madison's Federalist #10 is an extension of Locke into the practical matters of organizing a new constitution. This essay describes the classroom use of games, lecture and discussion to introduce students to these theorists.

The course begins with Madison, mainly because students can understand and apply the concepts of the entire argument much more quickly. The successful use of games and exercises in the classroom requires an immediate start to student participation, an active expectation of student roles in the course. Two hours of class time is sufficient to discuss and review Madison's argument. Time is spent on its implications for the role of the individual, the state, and the dynamics of politics.
Using Student Surveys: Suggested Strategies
Authors: Frank Steve
Published: May 2020

Student run survey projects are recommended in the instructor's manuals of many introductory American National Government texts. However, the suggested exercises are for non-random student surveys and/or contain few, if any instructions. James Bindley's instructor's manual for Burnham's Democracy In the Making, 2nd Ed. is typical when he writes:

Have your students conduct a poll. If they can go out in the community, the experience is valuable. Even a campus poll can be meaningful, particularly if you utilize actual questions from a national survey to enable your students to compare and contrast local student opinions with the national norms.

In the Summer, 1980 edition of News John Seltz described in “Public Opinion: Polling and Data Analysis,” his experiences using personal surveys developed and carried out by his Presidency and Congress courses. He contended that such exercises provided many benefits to students, especially in upper level undergraduate courses.
Teaching Campaign Finance with Federal Election Commission Resources
Authors: Wilcox Clyde
Published: May 2020

Many Political Science courses include sections on campaign finance activity. Courses on Congress and on the Presidency may include sections on the financing of elections for these offices, and courses on campaigns and elections will probably cover campaign finance. In addition, courses on interest groups and on parties may include sections that focus on the activities of these actors in financing campaigns for public office.

The Federal Election Commission can provide an assortment of materials that may be useful in teaching about campaign finance. Some of these materials are most useful as sources of data for lecture preparation, while other offerings can be used as part of student projects or papers. In the sections below, these materials will be described, and some classroom uses will be suggested.
American Government
Authors: Blomquist David
Published: May 2020

Most instructors burdened with the sometimes thankless task of teaching an introductory survey course in American government wince at the suggestion that their class is somehow a primer in current affairs. No wonder, for most of us who teach that introductory course expend a great deal of effort to ensure that our readings, our lectures, and our class discussion carefully delineate the difference between political science and political speculation.

Yet I fear many of us are so cautious that we wind up throwing the baby out with the bath water. The vast majority of students in our survey courses will not go on to graduate school in political science; indeed, at many institutions, the majority of enrollees in the introductory class may not even be political science majors. Most will become bankers, lawyers, scientists, engineers — in short, “ordinary” citizens rather than full-time, professional observers of politics. In strikes me that the greatest legacy the survey course can provide these students is an inclination to think twice about politics —an appreciation that politics and political choices are rarely as simple or straightforward as they seem in headlines.