bluuebunny/crossref_metadata_2025 huggingface dataset:
LO61: Test characteristics of high sensitivity troponin T performed at emergency department arrival for acute myocardial infarction in patients with reduced kidney function
Authors: McRae A. D. , Vatanpour S. , Ji J. , Yang H. , Southern D. , Wang D. , Seiden-Long I. , DeKoning L. , Graham M. , Lang E. S. , Innes G. , Andruchow J. E. , Kavsak P. , James M.
Published: May 2018

Introduction: Patients with chronic kidney disease (CKD) are at high risk of cardiovascular events, and have worse outcomes following acute myocardial infarction (AMI). Cardiac troponin is often elevated in CKD, making the diagnosis of AMI challenging in this population. We sought to quantify test characteristics for AMI of a high-sensitivity troponin T (hsTnT) assay performed at emergency department (ED) arrival in CKD patients with chest pain, and to derive rule-out cutoffs specific to patient subgroups stratified by estimated glomerular filtration rate (eGFR). We also quantified the sensitivity and classification performance of the assays limit of detection (5 ng/L) and the FDA-approved limit of quantitation (6 ng/L) for ruling out AMI at ED arrival. Methods: Consecutive patients in four urban EDs from the 2013 calendar year with suspected cardiac chest pain who had a Roche Elecsys hsTnT assay performed on arrival were included f. This analysis was restricted to patients with an eGFR< 60 ml/min/1.73m2. The primary outcome was 7-day AMI. Secondary outcomes included major adverse cardiac events (death, AMI and revascularization). Test characteristics were calculated and ROC curves were generated for eGFR subgroups. Results: 1416 patients were included. 7-day AMI incidence was 10.1%. 73% of patients had an initial hsTnT concentration greater than the assays 99th percentile (14 ng/L). TCurrently accepted cutoffs to rule out MI at ED arrival ( 5 ng/L and 6 ng/L) had 100% sensitivity for AMI, but no patients with an eGFR less than 30 ml/min/1.73M had hsTnT concentrations below these thresholds. We derived eGFR-adjusted cutoffs to rule out MI with sensitivity >98% at ED arrival, which were able to rule out 6-42% of patients, depending on eGFR category. The proportion of patients able to be accurately ruled-in with a single hsTnT assay was substantially lower among patients with an eGFR <30 ml/min/1.73m2 (6-20% vs 25-43%). We also derived eGFR-adjusted cutoffs to rule-in AMI with specificity >90%, which accurately ruled-in up to 18% of patients. Conclusion: Cutoffs achieving acceptable diagnostic performance for AMI using single hsTnT sampling on ED arrival may have limited clinical utility, particularly among patients with very low eGFR. The ideal diagnostic strategy for AMI in patients with CKD likely involves serial high-sensitivity troponin testing with diagnostic thresholds customized to different eGFR categories.
LO87: iPad distraction during intravenous cannulation in the pediatric emergency department: a randomized clinical trial
Authors: Ma K. , Ali S. , Dow N. , Vandermeer B. , Issawi A. , Kin S. Scott , Beran T. , Graham T. A.D. , Curtis S. , Jou H. , Hartling L.
Published: May 2018

Introduction: Intravenous (IV) cannulation is commonly performed in emergency departments (ED), often causing substantial pain and distress. Distraction has been shown to reduce child-reported pain, but there is currently little published about the effects of using iPad technology as a distraction tool. Our primary objective was to compare the reduction of pain and distress using iPad distraction (games, movies, books of the child’s choice) in addition to standard care, versus standard care alone. Methods: This randomized clinical trial, conducted at the Stollery Childrens Hospital ED, recruited children between ages 6 to 11 years requiring IV cannulation. Study arm assignment was performed using REDCaps randomization feature. Due to the nature of the intervention, blinding was not possible for the children, parents or research and ED staff, but the data analyst was blinded to intervention assignment until completion of analysis. Pain, distress, and parental anxiety were measured using the Faces Pain Scale-Revised, the Observed Scale of Behavioural Distress-Revised, and the State Trait Anxiety Inventory, respectively. The pain scores and observed behavioural distress scores were compared using the Mann-Whitney U test. Other co-variates were analyzed using a linear regression analysis. Results: A total of 85 children were enrolled, with 42 receiving iPad distraction and 43 standard care, of which 40 (95%) and 35 (81%) children received topical anesthesia, respectively (p=0.09). There were 40 girls (47.1%) with a mean age of 8.32 +/− 1.61 years. The pain scores during IV cannulation (p=0.35) and the change in pain score during the procedure compared to baseline (p=0.79) were not significantly different between the groups, nor were the observed distress scores during IV cannulation (p=0.09), or the change in observed distress during the procedure compared to baseline (p=0.44). A regression analysis showed children in both groups had greater total behavioural stress if it was their first ED visit (p=0.01), had prior hospitalization experience (p=0.04) or were admitted to hospital during this visit (p=0.007). A previous ED visit, however, was predictive of a greater increase in parental anxiety from baseline (p=0.02). When parents were asked whether they would use the same methods to manage pain for their child, parents of the iPad group were more likely to say yes than were parents of the standard care group (p=0.03). Conclusion: iPad distraction during IV cannulation in school-aged children was not found to decrease pain or distress more than standard care alone, but parents preferred its use. The effects of iPad distraction may have been over-shadowed by potent topical anesthetic effect. Future directions include exploring iPad distraction for other age groups, and studying novel technology such as virtual reality and interactive humanoid robots.
LO91: Relationship between pain, opioid treatment, and delirium in emergency department elderly patients
Authors: Daoust R. , Paquet J. , Lee J. , Gouin E. , Voyer P. , Pelletier M. , Nadeau A. , Boucher V. , Emond M.
Published: May 2018

Introduction: Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) favor the development of delirium in vulnerable elderly patients. Poorly controlled pain, and paradoxically opioid pain treatment, has also been identified as a trigger for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in elderly ED patients. Methods: A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged 65 years old, waiting for care unit admission between February and May 2016, who were non-delirious upon ED arrival, independent or semi-independent for their activities of daily living, and had an ED stay of at least 8 hours were included. Delirium assessments were made twice a day for their entire ED stay and for the first 24 hours in the hospital ward using the Confusion Assessment Method (CAM). Pain intensity was evaluated using a visual analog scale (0-100) during the initial interview, and all opioid treatments were documented. Results: A total of 338 patients were included; 51% were female, mean age was 77 years (SD: 8). Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean delay of 47 hours (SD: 19) after ED admission. Among patients with pain intensity 60, 22% experienced delirium compared to 10.7% for patients with pain <60 (p<0.05). No significant association was found between opioid consumption and delirium (p=0.22). Logistic regression controlling for age, sex, ED stay duration, and opioids intake showed that patients with pain intensity 60 are 2.6 (95%CI: 1.2-5.9) more likely to develop delirium than patients who had pain <60. Conclusion: Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to the decrease of delirium episodes.
MP01: Use of an unmanned aerial vehicle to provide situational awareness in a simulated mass casualty incident
Authors: Sibley A. K. , Jain T. , Nicholson B. , Butler M. , David S. , Smith D. , Atkinson P.
Published: May 2018

Introduction: Situational awareness (SA) is essential for maintenance of scene safety and effective resource allocation in mass casualty incidents (MCI). Unmanned aerial vehicles (UAV) can potentially enhance SA with real-time visual feedback during chaotic and evolving or inaccessible events. The purpose of this study was to test the ability of paramedics to use UAV video from a simulated MCI to identify scene hazards, initiate patient triage, and designate key operational locations. Methods: A simulated MCI, including fifteen patients of varying acuity (blast type injuries), plus four hazards, was created on a college campus. The scene was surveyed by UAV capturing video of all patients, hazards, surrounding buildings and streets. Attendees of a provincial paramedic meeting were invited to participate. Participants received a lecture on SALT Triage and the principles of MCI scene management. Next, they watched the UAV video footage. Participants were directed to sort patients according to SALT Triage step one, identify injuries, and localize the patients within the campus. Additionally, they were asked to select a start point for SALT Triage step two, identify and locate hazards, and designate locations for an Incident Command Post, Treatment Area, Transport Area and Access/Egress routes. Summary statistics were performed and a linear regression model was used to assess relationships between demographic variables and both patient triage and localization. Results: Ninety-six individuals participated. Mean age was 35 years (SD 11), 46% (44) were female, and 49% (47) were Primary Care Paramedics. Most participants (80 (84%)) correctly sorted at least 12 of 15 patients. Increased age was associated with decreased triage accuracy [-0.04(-0.07,-0.01);p=0.031]. Fifty-two (54%) were able to localize 12 or more of the 15 patients to a 27x 20m grid area. Advanced paramedic certification, and local residency were associated with improved patient localization [2.47(0.23,4.72);p=0.031], [-3.36(-5.61,-1.1);p=0.004]. The majority of participants (78 (81%)) chose an acceptable location to start SALT triage step two and 84% (80) identified at least three of four hazards. Approximately half (53 (55%)) of participants designated four or more of five key operational areas in appropriate locations. Conclusion: This study demonstrates the potential of UAV technology to remotely provide emergency responders with SA in a MCI. Additional research is required to further investigate optimal strategies to deploy UAVs in this context.
MP02: Paramedic recognition of paroxysmal supraventricular tachycardia
Authors: Sample S. , Shortt C. , Hanel E. , M. Welsford
Published: May 2018

Introduction: Paroxysmal supraventricular tachycardia (PSVT) is a common group of arrhythmias that Advanced Care Paramedics (ACPs) can often manage with vagal maneuvers, adenosine, and/or cardioversion, provided that they correctly identify the rhythm. The purpose of this study is to determine the accuracy of ACP identification of PSVT. Methods: Following ethics approval, all calls for patients 18 years with a 12-lead ECG available, who were assessed by ACPs within a region of western Ontario between July 2015 - December 2015 and had a documented heart rate>150bpm, were included. Paramedic call reports were retrospectively reviewed for study data, including documentation of ACP identified PSVT. The reference standard was consensus between an EMS fellow and prehospital physician who adjudicated each ECG for the presence of PSVT in a blinded, independent fashion. In the event of a disagreement, a third, blinded prehospital physician was used for consensus. Results: Of the 442 patients included, 197 (45%) were male and the median age [Interquartile range(IQR)] was 70.0 (58.0-82.8). ACPs identified 74 (16.7%) patients as having PSVT while 38 (8.6%) were identified by physicians as having PSVT. 44.7% of patients with physician identified PSVT had a history of previous arrhythmia, compared to 30.9% of patients with no physician identified PSVT (p=0.10). They were also significantly younger 58.5 (48.5-72.0) compared to those without physician identified PSVT 69.0 (60.0-84.0) (P=0.0010). Sensitivity of ACP identified PSVT was 97.4% (95%CI:86.2%-99.9%) and specificity was 90.8% (95%CI:87.6%-93.5%). The positive predictive value (PV) of ACP identified PSVT was 50.0% (95%CI:42.3%-57.7%), the negative PV was 99.7% (95%CI:98.1%-99.9%), the positive likelihood ratio (LR) was 10.6 (95%CI:7.8-14.5) and negative LR was 0.03 (95%CI:0.0-0.2). Moderate inter-rater agreement was seen between initial ECG interpretations (kappa= 0.42, 95%CI:0.29-0.54) by the fellow and prehospital physician, while agreement was higher (good) between the two prehospital physicians (kappa=0.76, 95%CI:0.55-0.96). Conclusion: These results indicate that ACPs are adept at identifying PSVT, but are prone to false positives. Given the relatively good sensitivity and specificity seen in this investigation, future studies should investigate ACP recognition of specific rare arrhythmias (antidromic accelerated atrial fibrillation) that may require different management including avoidance of adenosine.
MP04: Analysis of a needs-based assessment of paramedic continuing education
Authors: Davis M. , Leggatt L. , Van Aarsen K. , Romano S.
Published: May 2018

Introduction: To determine trends in identified self-perceived knowledge deficits of paramedics, training barriers and desired methods of self-directed education. Methods: A written survey was delivered to all paramedics in an Ontario base-hospital. Respondents were asked to identify deficits from a 37-point, anatomic systems-based list. Preferred educational modalities to address knowledge deficits and factors taken into consideration when choosing self-directed education were captured. Top 5 perceived deficit topics, number of perceived deficits, top 5 factors associated with training modality chosen and factors taken into consideration for choosing training modalities, were compared against paramedic age, training (Advanced Care Paramedic; ACP, or Primary Care Paramedic; PCP) and primary location of practice (urban, rural, mixed setting). Results: Of 1262 paramedics, 746 (59.11%) completed the survey. PCPs had a higher report of deficit in both neonatal resuscitation and arrhythmia than ACPs (48.3% vs 58.8%, p=0.015; 40.3% vs 58.5%, p<0.001). Paramedics who listed rural as their primary practice location were more likely to report a deficit in pediatric respiratory disorder than those with a mixed urban/rural and primary urban practice (65.9% vs 46.3%, p=0.000; 65.9% vs 45.9%, p=0.001;) as well as a higher median number of listed deficits (9.00 vs 6.00 vs 6.00, p<0.001). ACPs were more likely to consider scheduling, location/ease of attending and cost as barriers than PCPs (85.4% vs 63.8%, p=0.000; 69.5% vs 51.4%, p=0.002; 69.5% vs 39.5%, p=0.000) while reporting an increased desire for webinar material than PCPs (56.1% vs 40.4%, p=0.007). There were no significant differences found by age. Conclusion: Targeted educational needs-based assessments can help ensure appropriate topics are delivered in a fashion that overcomes identified barriers to self-directed learning. From our analysis, increased awareness of ease of attending sessions and preferred modalities, such as webinars may be beneficial; especially for ACPs who require more annual continuing educational hours. Paramedics in rural locations may require increased continuing education, especially for rarely encountered, high risk situations, such as pediatric critical care. These findings can help direct future education in our system and others.
MP07: Rate of return: prevalence and correlates of revictimization among sexual and domestic assault cases presenting to the emergency department
Authors: Drumm A. , Muldoon K. , Blaskovits F. , Leach T. , Heimerl M. , Sampsel K.
Published: May 2018

Introduction: Many survivors of sexual and domestic assault return to violent environments following post-assault care. The objective of this study was to estimate the annual prevalence of revictimization and examine factors associated with return emergency department (ED) visits following their initial encounter for sexual or domestic assault. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital is the only program in Ottawa offering emergency and forensic care for survivors of sexual assault and domestic violence. Information on demographics, assailant characteristics and clinical presentation were extracted from the SAPACP case registry (January 1 2015- January 31 2016). We conducted descriptive analyses to describe the study sample, and bivariable and multivariable logistic regression modelling to assess factors most strongly associated with revictimization using odds ratios (OR), adjusted OR (AOR) and 95% confidence intervals (CI). Results: Among 377 unique patients seen at the SAPACP, there were 409 encounters for sexual and domestic violence. There were 24 revictimization cases (6.4%) with the number of repeat visits ranging from 2-6. There were 343 (91.0%) female patients and 182 (48.3) under the age of 25. There were 243 (64.5%) sexual assaults, 125 (33.2%) physical assaults, and 42 (11.1%) verbal assaults. Compared to patients who presented once, revictimized patients were more likely to have experienced violence from a current or former intimate partner (AOR:3.02, 95% CI:1.24-7.34), have a substance use disorder (AOR:5.57, 95% CI:2.11-14.68), and were more likely to be taking anti-depressants (AOR:3.34, 95% CI:1.39-8.01). Conclusion: This study has identified a high prevalence of revictimization, with some clients being revictimized as many as 6 subsequent times. Key factors to help identify patients at risk of revictimization are assaults by intimate partners, having substance use problems, and being on antidepressants. Reducing revictimization and preventing further violence is a critical component of care to ensure survivors are safe following their ED encounter.
MP11: Underreport of incident delirium in elderly patients treated in the emergency department
Authors: Emond M. , Nadeau A. , Boucher V. , Voyer P. , Pelletier M. , Gouin E. , Daoust R. , Berthelot S. , Lamontagne M. , Morin M. , Lemire S. , Vu T. Minh , Rheault M. , Juneau L. , Le Sage N. , Lee J.
Published: May 2018

Introduction: It is documented that physicians and nurses fail to detect delirium in more than half of cases from various clinical settings, which could have serious consequences for seniors and for our health care system. The present study aimed to describe the rate of documented incident delirium in 5 Canadian Emergency departments (ED) by health professionals (HP). Methods: This study is part of the multicenter prospective cohort INDEED study. Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Delirium status was assessed twice daily using the Confusion Assessment Method (CAM) by trained research assistants (RA). HP reviewed patient charts to assess detection of delirium. HP had no specific routine detection of delirious ED patients. Inter-observer agreement was realized among RA. Comparison of detection between RA and HP was realized with univariate analyses. Results: Among the 652 included patients, 66 developed a delirium as evaluated with the CAM by the RA. Among those 66 patients, only 10 deliriums (15.2%) were documented in the patients medical file by the HP. 54 (81.8%) patients with a CAM positive for delirium by the RA were not recorded by the HP, 2 had incomplete charts. The delirium index was significantly higher in the HP reported group compared to the HP not reported, respectively 7.1 and 4.5 (p<0.05). Other predictive delirium variables, such as cognitive status, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between groups. Conclusion: It seems that health professionals missed 81.8% of the potential delirious ED patients in comparison to routine structured screening of delirium. HP could identify patients with a greater severity of symptoms. Our study points out the need to better identify elders at risk to develop delirium and the need for fast and reliable tools to improve the screening of this disorder.
MP13: Accuracy of Korean triage and acuity scale when pain severity is used as a modifier
Authors: Kim M. , Park J.
Published: May 2018

Introduction: Accurate triage is important because under-triage may delay critical care for emergent patients and over-triage may inhibit efficient management of emergency department (ED) resources. In Korea, the Korean Triage and Acuity Scale (KTAS) was developed based on the CTAS in 2015. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient’s severity when degree of pain was used as a modifier. Methods: This was a retrospective observational cohort study, conducted in an ED of urban tertiary university hospital with more than 90,000 visits per year. We studied adult patients who visited the ED from January 2016 to June 2016. Patients were devided into pain group and non-pain group according to whether the degree of pain was used as a modifier in the KTAS evaluation. We used acute area registration, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and hospital mortality as markers to determine urgent patients. To evaluate discriminative ability of KTAS, the odds ratios of each KTAS values compared to KTAS 3 for the urgent patients were calculated. And to compare the predictive power of KTAS for urgent patients between the two groups, the area under the receiver operating characteristic (ROC) curves were compared by DeLongs method. Results: There were 9,175 (37.8%) patients in the pain group and 15,078 (62.2%) patients in the non-pain group. When KTAS was assessed as 2, only 20.3% of the patients in the pain group were registered to the acute area, while 71.2% of the patients in the non-pain group were registered to the acute area (p<0.001). And the proportion of emergency procedure, admission, ICU admission, and mortality was also higher in patients with pain group. Similarly, in the patients of KTAS 3, the proportion of urgent patients was higher in the non-pain group except emergency operation. The odds ratio for the occurrence of urgent patients decreased as the KTAS value increased in both groups, however, the difference between the odds ratios of each KTAS was more evident in the non-pain group. In pain group, compared to patients with KTAS 3, the odds ratio (95% CI) for acute area registration were 2.32 (1.92-2.80), 0.61 (0.51-0.73), and 0.35 (0.23-0.53) for patients with KTAS 2, 4, 5, respectively; in non-pain group, odds ratio were 5.59 (5.09-6.13), 0.28 (0.25-0.32), and 0.13 (0.10-0.16). The non-pain group showed better predictive power of KTAS for acute area registration than pain group; AUC (95% CI), 0.864 (0.861-0.867) vs. 0.810 (0.802-0.818), p<0.0001). The predictability of KTAS was also higher in non-pain group for emergency procedure, emergency operation, admission, and ICU admission. Conclusion: We have confirmed that the use of pain severity as a modifier in KTAS is a factor affecting accuracy. The acuity level is overestimated when pain severity is used as modifier in KTAS evaluation.
MP16: Development, implementation and evaluation of a curriculum for healthcare students working at electronic dance music events
Authors: Schonnop R. , Ha D.
Published: May 2018

Introduction: Mass Gathering Medicine (MGM) is a growing field within emergency medicine (EM) and providing care at electronic dance music events (EDMEs) is an increasingly popular activity with MGM groups. Often, health care students are allowed to participate. However, there is a lack of documented curricula to train junior learners in providing medical care at these events. To address this, we developed and initiated an interprofessional, simulation-based workshop for University of Alberta health care students interested in working at EDMEs. Methods: We used Kerns six-step approach to develop the workshops. Our MGM Interest Group identified a need for educational sessions in toxicology case management at EDMEs. A subsequent literature review revealed a paucity of pre-existing curricula on this topic for MGM learners. We created goals and objectives for the workshops, reflecting the knowledge, skills and attitudinal competencies required to provide appropriate medical care at these events. The workshops were implemented and evaluated in November 2016 and 2017. Results: A total of 44 medical and nursing students attended the workshops. An EM resident and staff physician, both with prior experience working at EDMEs, led each session. Each workshop began with a short didactic lecture followed by two hours of case-based training using two standardized patients and a high fidelity simulator. Topics were chosen based on previously published articles describing medical cases seen at EDMEs. The simulation replicated the actual space, noise and equipment available at the medical tents at these events. Two interprofessional learner groups took turns managing a different set of 3 patients: Set 1-opioid overdose (OD), alcohol/vomiting, sympathomimetic OD; Set 2-opioid OD not responsive to naloxone, anticholinergic/seizure, OD with hyperthermia. Initial assessment, medical management and team communication skills were emphasized. Debriefing was provided to learners immediately after each set of cases. After each workshop, the learners completed evaluation forms utilizing both Likert scale and open-ended responses. Overall, students were extremely complimentary about the workshop structure, content and communication skills teaching. They were especially appreciative of the opportunity to participate in their first interprofessional team experience. Conclusion: To address local needs, a well-received simulation-based workshop was created to train students in toxicology case management at EDMEs. Future work will include using this workshop in a just-in-time fashion before upcoming EDMEs and documenting students actual use of skills taught (Kirkpatrick level 3). The workshop will also be further modified to implement more detailed interprofessional objectives and can provide a venue for EM residents to practice teaching interprofessional education competencies as part of their CanMEDS Scholar role.
MP17: Evaluating the efficacy of the flipped classroom model in postgraduate emergency medicine training
Authors: Krawchenko-Shawarsky A. O. , Pham C. , Oliver Z. , Ffrench C.
Published: May 2018

Introduction: As the value of interactive teaching becomes increasingly recognized, the Flipped Classroom model is receiving more attention in the medical education community. In this model, learners master core declarative knowledge through self-learning prior to class and then expand upon this learning with integrative class exercises. The objective of this study was to assess the effectiveness of the new Flipped Classroom in a Canadian Emergency Medicine postgraduate program. Methods: The residents and staff were educated on the new model. An online questionnaire was sent to all EM residents and staff who had participated in the program 9 months after implementation. The survey tool assessed the participants opinions on utility, time-management, effectiveness in learning material, sustainability, collaboration with other members and overall impressions. Resident scores on national preparatory examinations including the Canadian In-Training Examination (CITE) and the American Board of Emergency medicine (ABEM) were compared before and after implementation of the new model. Results: Teaching staff were trained in the Flipped Classroom model and the majority of teaching sessions for the 2016 academic year were carried out using this paradigm. In addition, third year postgraduates received intensive training in the theory and implementation of interactive teaching techniques. A curriculum renewal committee generated objectives for each teaching session and suggested materials for learner pre-reading. Conclusion: Overall, both residents and staff physicians indicated that the flipped classroom model is a better format for EM academic day learning. Residents and staff collaborated more and felt more engaged during academic day. Residents spent more time preparing for the sessions with the new model, while staff spent less time preparing. Paired comparisons of same residency years for test exam scores using Wilcoxon signed-rank test showed an improvement in both CITE and ABEM exam test scores. In conclusion, the new flipped classroom model produced improvements in educational experience, satisfaction, and test examination scores.
MP19: Interprofessional airway microskill checklists facilitate the deliberate practice of direct intubation with a bougie and airway manikins
Authors: French J. P. , David K. , Benjamin S. , Fraser J. , Mekwan J. , Atkinson P.
Published: May 2018

Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Mircroskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Endotracheal intubation is a complex task with a clinically significant complication and failure rate. Methods: Two doctors and three nurses developed stepwise team microskills checklist from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 36 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. The microskills checklist was used in four phases: 1. Group discussion of each microskill step 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback. Changes are recorded. 3. Total task run though without interruption. Changes are recorded. 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Results. Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 13/30, RNs 7/16. The commonest changes in practice were patient positioning (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 4.8/5). Conclusion: Microskills checklist facilitate endotracheal intubation with a bougie skill development in interprofessional teams in this provisional analysis.
MP20: ImageSim - performance-based medical image interpretation learning system
Authors: Boutis K. , Pecarcic M. , Pusic M.
Published: May 2018

Introduction: Medical images (e.g. radiographs) are the most commonly ordered tests in emergency medicine. As such, emergency medicine physicians are faced with the task of learning the skill of interpreting these images to an expert performance level by the time they provide opinions that guide patient management decisions. However, discordant interpretations of these images between emergency physicians and expert counterparts (e.g. radiologists) is a common cause of medical error. In pediatrics, this problem is even greater due to the changing physiology with age. Methods: ImageSim (https://imagesim.com/) is an evidence-based on-line learning platform derived and validated over an 11 year period (https://imagesim.com/research-and-efficacy/). This learning system incorporates the concepts of cognitive simulation, gamification, deliberate practice, and performance-based competency in the presentation and interpretation of medical images. Specifically, ImageSim presents images as they are experienced in clinical practice and incorporates a normal to abnormal ratio is representative of that seen in emergency medicine. Further, it forces the participant to commit to the case being normal or abnormal and if abnormal, the participant has to visually locate the specific area of pathology on the image. The participant submits a response and gets text and visual feedback with every case. After each case, the participant gets to play again until they reach a desired competency threshold (80% is bronze resident; 90% silver staff emergency medicine physician; 97% gold radiologist). Importantly, the learning experience also emphasizes deliberate practice such that the learning system provides hundreds of case examples and therefore each participants performance has the opportunity to improve along their individual learning curve. Results: Course selection was made based on known medical image interpretation knowledge gaps for practicing emergency physicians. Currently, ImageSim live courses include pediatric musculoskeletal radiographs (2,100 cases, 7 modules) and pediatric chest radiographs (434 cases). In 2018, we will also release a pediatric point-of-care ultrasound course (400 cases, 4 modules) and the pre-pubertal female genital examination (150 cases). For a demo, go to https://imagesim.com/demo/. Using ImageSim, the deliberate practice of about 120 cases (1 hour time commitment) increases accuracy on average by 15%. Currently integrated into 10 emergency medicine training programs and there are about 300 continuing medical education world-wide participants. Conclusion: While acquiring mastery for these images may take years to acquire via clinical practice alone, this learning system can potentially help achieve this in just a few hours.
MP21: Global emergency medicine fellowship: establishing a global EM training program at Queen’s University
Authors: Collier A. , Bartels S. A. , Messenger D.
Published: May 2018

Introduction: Global Emergency Medicine (Global EM) is growing rapidly as an academic niche in Canada. An increasing number of Canadian emergency physicians work internationally as part of their practice, and trainees consistently seek out international projects and electives. For the most part however, residents have had to create their own training opportunities as formal Global EM fellowship training has been lacking in Canada. To address this identified need, Queens University established a Global EM fellowship, the first of its kind in the country. Methods: The fellowship is designed to provide the skills necessary for an academic career in Global Emergency Medicine. Curriculum and objectives are modeled on similar well-established fellowships in the United States. Areas of expertise include emergency medicine systems development, humanitarian medicine, disaster response, public health, tropical medicine, research, administration and education. Fellows have the opportunity to tailor their training according to their specific interests within these domains. Importantly, the fellowship provides direct mentorship from academic global EM and public health physicians, and networking opportunities within the global health sphere. Results: The two-year fellowship curriculum is divided between: 1) coursework to complete a Master of Public Health (MPH) Degree 2) fieldwork 3) relevant international emergency medicine training courses and 4) clinical work in the emergency departments at the Kingston Health Sciences Center. The Queens Global EM fellowship admitted its first fellow in August 2017. To date, the inaugural fellow has completed the MissionCraft Leadership in Disaster Relief course as well as a Humanitarian U Disaster and Response course, in addition to submitting a research grant as a co-principal investigator, starting coursework for an MPH degree and giving several invited lectures on humanitarian medicine. The fellow also travelled to Lebanon to support research in collaboration with aid organizations responding to the Syrian crisis. Upcoming fieldwork involves teaching at a newly established emergency medicine residency program in Haiti as well as a humanitarian crisis deployment. Conclusion: In response to a lack of formal international emergency medicine training opportunities in Canada, Queens University has established a Global Emergency Medicine fellowship. The fellowship aims to provide protected time, access to field opportunities and dedicated mentorship to develop the skills necessary to succeed as an academic Global EM physician. We believe it provides a unique opportunity to significantly expand fellows experiences in global health fieldwork, education and research while continuing to practice in a Canadian tertiary emergency department.
MP28: Reducing door-to-needle times across Alberta to 36 minutes
Authors: Kamal N. , Jeerakathil T. , Smith E. E. , Mann B. , Bestard J. , Lang E. S. , Hill M.
Published: May 2018

Introduction: The effectiveness of intravenous alteplase is highly time dependent, and very short door-to-needle times (DNT) of 30 minutes or less have been reported in single centre hospitals, but never in an entire population. QuICR (Quality Improvement and Clinical Research) Alberta Stroke Program aimed to reduce DNT to a median of 30 minutes across the Canadian province of Alberta. Methods: We used the Improvement Collaborative Methodology from early 2015 to September 2016 with participation from all 17 Stroke Centres in Alberta. This methodology included 4 face-to-face workshops, site visits, webinars, data collection, data feedback, intensive process mapping, and process improvements. We compared data in the pre-intervention period from 2009-2014 (collected during the Alberta Provincial Stroke Strategy) to data in the post-intervention period from March 2016-February 2017 (collected during the QuICR DTN Collaborative). Data from January 2015-February 2016 were excluded, as improvements were being implemented during this time. Results: There were a total of 2,322 treated cases in the pre- and post-intervention periods. The results show that the median DNT dropped from 68 minutes (n=1846) in the pre-intervention period to 36 minutes (n=476) in the post-intervention period (p<0.001). There were reductions in DNT across all hospital types: median DNT dropped from 63 to 32 minutes in Urban Tertiary Centres (p<0.001), from 73 to 32 minutes in Community with 24/7 neurology (p<0.001), from 85 to 62 minutes in Community with limited/no neurology (p<0.001), and from 74 to 52.5 minutes in rural centres (p<0.001). Conclusion: There were 21.5 to 41 minute reductions in median DNT across all hospital types including smaller rural and community hospitals. A targeted multi-site improvement collaborative can be an effective intervention to reduce DNT across an entire population.
MP29: Creation of the CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist
Authors: Stiell I. G. , Scheuermeyer F. , Vadeboncoeur A. , Angaran P. , Eagles D. , Graham I. D. , Atzema C. , Archambault P. , Tebbenham T. , de Wit K. , McRae A. D. , Cheung W. J. , Deyell M. , Baril G. , Mann R. , Sahsi R. , Upadhye S. , Clement C. , Brinkhurst J. , Chabot C. , Gibbons D. , A.  , Skanes
Published: May 2018

Introduction: Patients with acute atrial fibrillation or flutter (AAFF) are the most common acute arrhythmia cases requiring care in the ED. Our goal was to adapt the existing Canadian Cardiovascular Society (CCS) AF Management Guidelines into an emergency physician-friendly best practices checklist. Methods: We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the CCS using the GRADE system. We used the Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. We created an Advisory Committee consisting of 14 academic and community emergency physicians, three cardiologists, one PhD methodologist, and two patients. The Advisory Committee communicated by a two-day face-to-face meeting, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues whose written feedback was further incorporated into the final approved version. Results: The final CAEP ED AAFF Guidelines are comprised of two algorithms and four sets of checklists, organized by 1) Assessment and Risk Stratification, 2) Rhythm and Rate Control, 3) Long-term Stroke Prevention with the CHADS-65 Algorithm, and 4) Disposition and Follow-up. The guidelines have been endorsed by CAEP and accepted for publication in the Canadian Journal of Emergency Medicine. During the consensus and feedback processes, we addressed a number of issues and concerns. We highlighted the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. One controversial recommendation is to consider rate control or transesophageal echocardiography guided cardioversion if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated. Conclusion: We have created the CAEP AAFF Best Practices Checklist which we hope will standardize and improve care of AAFF patients in all EDs across Canada. We believe that most of these patients can be managed rapidly and safely with ED rhythm control, early discharge, and appropriate use of anticoagulants.
MP31: Debriefing critical incidents in health care: a review of the evidence
Authors: Conrad E. Katherine , Morrison R. DB.
Published: May 2018

Introduction: Emergency health care providers (HCPs) regularly perform difficult medical resuscitations that require complex decision making and action. Critical incident debriefing has been proposed as a mechanism to mitigate the psychological effect of these stressful events and improve both provider and patient outcomes. The purpose of this updated systematic review is to determine if HCPs performing debriefing after critical incidents, compared to no debriefing, improves the outcomes of the HCPs or patients. Methods: We performed a librarian assisted systematic review of OVID Medline, CINAHL, OVID Embase and Google Scholar (January 2006 to February 2017) No restrictions for language were imposed. Two investigators evaluated articles independently for inclusion criteria, quality and data collection. Agreement was measured using the Kappa statistic and quality of the articles were assessed using the Downs and Black evaluation tool. Results: Among the 658 publications identified 16 met inclusion criteria. Participants included physicians, nurses, allied health and learners involved in both adult and pediatric resuscitations. Findings suggest that HCPs view debriefing positively (n=7). One moderate quality study showed that debriefing can enhance medical student and resident knowledge. Several studies (n=8) demonstrated at least some improvement in CPR and intubation related technical skills. Debriefing is also associated with improved short term patient survival but not survival to discharge (n=5). Two studies reported benefits to HCPs mental health as evidenced by improved ability to manage grief and decreased reported symptoms of Post-Traumatic Stress Disorder (PTSD). Conclusion: We found HCPs value debriefing after critical incidents and that debriefing is associated with improved HCP knowledge, skill and well-being. Despite these positive findings, there continues to be limited evidence that debriefing significantly impacts long term patient outcomes. Larger scale higher quality studies are required to further delineate the effect of structured debriefing on patient and provider outcomes.
MP37: Conceptualizing unnecessary care in emergency departments (ED): qualitative interviews with ED physicians and site chiefs
Authors: Hill N. , Krebs L. D. , Villa-Roel C. , Rowe B. H.
Published: May 2018

Introduction: Unnecessary care is an increasingly commonly used term in medicine. Previous survey research suggests that definitions of unnecessary care vary within and among professional and patient groups. This research explores how emergency physicians and administrators understand the term unnecessary care. Methods: Site chiefs and emergency physicians in an Alberta region were recruited through email and online surveys respectively for a qualitative study. One hour one-on-one in-depth interviews explored understandings of unnecessary care within the emergency department (ED) context. Interview transcripts underwent thematic analysis. Results: Five physicians and seven site chiefs completed interviews. Two key themes emerged. First, interviewees conceptualized unnecessary care as inappropriate or non-urgent presentations. This patient-centric view raised non-urgent ED presentations as a health system problem with complex components, including: lack of public knowledge of healthcare resources, shrinking comfort and scope of community providers and patient willingness to utilize other resources. Despite concerns over non-urgent visits, interviewees expressed that these patients still need to be seen, assessed and managed. The second conceptualization focused on over-investigation (and to lesser extent, treatment). This physician-centric conceptualization identified issues around: variation in physician risk tolerance, established decision rules with the allowable miss rates, patient expectation for testing or physician feeling that the patient was owed something or that patient would not accept their diagnosis/treatment without testing. Additionally, interviewees described patient characteristics that may initiate more aggressive investigation (e.g., patient reliability, follow-up care access, etc.). An overarching concern about the connection between unnecessary care and wasted resources was identified. Additionally, interviewees emphasized that patient conversations are outside the scope of unnecessary care despite their possible implications for limited time resources. Conclusion: A range of concepts surrounding unnecessary care in the ED were identified. Further exploring nuances of these conceptualizations may inform and improve the effectiveness of campaigns seeking to improve efficiency in practice and reduce inappropriate care. Additionally, this work provides an impetus for developing clearer concepts of care within the ED.