bluuebunny/crossref_metadata_2025 huggingface dataset:
P100: It’s more than just Travel CME: an embedded ethnography of a unique emergency medicine conference
Authors: Penciner R. , Dainty K.
Published: June 2016

Introduction: Travel-based continuing medical education (CME) has become a popular format for physicians looking to combine education with travel. However these programs do not usually include shared group activities and when they do, they are often social, sedentary events. Emergency Medicine Update (EMU) Europe is a unique biennial accredited CME program which combines high quality Emergency Medicine focused education with organized group physical and social activities in European locales. Methods: We undertook a participant observation-based ethnographic study of the EMU Europe program in Provence, France in 2015. Participant interviews and in-depth observation methods were used to understand (1) the impact of shared group activities on learning and (2) the ethos that is created during this type of program. Results: We describe three phenomena from the data that we feel are highly influential in the success of the program and impact on learning. The first is “social engagement and a sense of community”. Involvement in group physical and social activities supports more interactive learning and people affiliate with this as a group that they enjoy and feel good learning with. The second is “a stimulating escape”. This is the opportunity for high quality education and stimulating travel to be provided in an efficient package. The third is “the ‘flat’ faculty-learner relationships”. This is created through accessibility and innovative teaching and is a key component of the quality of the education. Conclusion: While each trip in and of itself might be unique, there appears to be some common elements - building a sense of community, providing a stimulating escape and choosing faculty with specific teaching styles - that contribute to the educational success of this model. We will discuss how this relates to medical education theory and how it is generalizable to other groups considering this type of program. To our knowledge this is the first empirical research in this area and improves our understanding of how to leverage this approach for more effective continuing medical education.
P104: Literature review of telemedicine for trauma patients in rural areas
Authors: Pichard-Jolicoeur A. , Mbakop-Nguebou M. , Joyce Dogba  , Labrie J. , Tounkara F.K. , Fleet R.
Published: June 2016

Introduction: Trauma is the leading cause of death among people under 40. With more than 7 million Canadians living over one hour’s travel from a level 1 or 2 trauma center, access to quality trauma care in Canada is a major concern. We recently reported that more than 40% of rural EDs across Canada were more than 300 km from levels 1 and 2 trauma centers. Direct transportation to trauma centers is therefore unusual and most trauma cases are initially managed in rural EDs. Assistance from trauma centers via telemedicine could thus be valuable in optimizing initial stabilization and inter-facility transfers. Objective: Is telemedicine a potentially effective intervention for improving rural trauma care? Methods: We conducted a literature review to examine the potential impact (number of transfers, transfer times, length of hospital stays and mortality) of telemedicine on rural trauma care. Two reviewers independently searched PubMed, Embase and Cochrane databases with key words / concept combinations: telemedicine, trauma and rural. Articles included in the final review had to address the question with specific methodologies. After duplicate removal, 312 articles were found relevant. After independent review of titles and abstracts, only 25 articles pertained to the specific question. Only three studies met inclusion criteria. Results: These studies reported 187 successful teleconsultations in the context of rural trauma care, 29 of which involved significant interventions (8 interventions potentially lifesaving). Some unnecessary inter-facility transfers were avoided. However, transfer times to trauma centers and length of hospital stays appeared slightly longer with telemedicine. Conclusion: The literature on the efficacy of telemedicine in trauma care is scarce, with only three studies addressing the question. Conclusions generally favor telemedicine, but additional research must should determine its impact and better understand the barriers/facilitators to the implementation of telemedicine for rural trauma care.
P110: Relapse in patients managed in the emergency department for acute asthma: a systematic review
Authors: Rowe B.H. , Hill J. , Arrotta N. , Villa-Roel C. , Dennett E.
Published: June 2016

Introduction: Despite the provision of evidence-based care, approximately 15% of patients discharged from the emergency department (ED) after being treated for asthma exacerbations will relapse within two weeks. This study summarizes the evidence regarding relapses and factors associated with increased relapse in patients discharged from EDs after being treated for asthma exacerbations. Methods: Comprehensive literature searches were conducted in seven electronic databases; manual and grey literature searches were performed. Studies tracking outcomes for adults after ED management and discharge were included. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Risk of Bias (RoB) tools. Studies were summarized using medians and interquartile ranges (IQR) or mean and standard deviation (±SD), as appropriate. Results: From 793 potentially relevant citations, 178 articles underwent full text review and 10 studies involving 32,923 patients were included. The majority of the studies were of high quality according to NOS and RoB tools. Relapse proportions were 8±3%, 12±4%, and 14±6% at one, two, and four weeks, respectively. Female sex was the most common statistically significant reported factor associated with an increased risk of relapse within 4 weeks of ED discharge for acute asthma. Other factors significantly associated with relapse were past healthcare utilization and symptom duration. Conclusion: After ED management and discharge of acute asthma, a considerable proportion of patients will relapse within the first four weeks. Factors such as female sex, past healthcare utilization, and symptom duration were commonly and significantly associated with relapse occurrence. Identifying patients with these features could provide guidance to clinicians during the ED-discharge decision-making.
P112: Cost of hypoglycemia associated with diabetes mellitus: a systematic review of the literature
Authors: Alexiu C. , Kirkland S.W. , Jelinski S. , Chuck A. , Campbell S. , Rowe B.H.
Published: June 2016

Introduction: Diabetes mellitus (DM) is a major chronic disease. Many patients with DM suffer hypoglycemic episodes that may be mild, moderate or severe, requiring ambulance and emergency department (ED) services. The cost of these DM-associated hypoglycemic episodes in the ED is not well understood. This study identified literature on DM-associated hypoglycemia costs that were incurred in acute care settings, with particular interest in the ED setting. Methods: The methods of this systematic review were based on an a priori protocol. The literature searches involved 12 databases. Study selection and quality assessment were conducted independently by two reviewers. Costs from included studies were standardized to year 2014 Canadian dollars. Mean with standard deviation (SD) and median costs with interquartile range (IQR) were calculated whenever possible. Results: The systematic search yielded 1,164 studies and 62 were included. The largest proportion of studies (45%) originated from USA data. Quality of included studies varied widely. Although none of the studies were purely a cost analysis of DM-associated hypoglycemia in the ED, 15 studies reported some ED costs. Median DM-associated hypoglycemic episode costs were $1,187.15 in the ED and $1,288.92 irrespective of setting. More severe episodes were more costly; costs were 8.5 times higher in the inpatient setting than in the ED. Episode costs were 18-45% higher for patients with Type 2 DM than Type 1. Direct costs comprised 80% of total costs. Conclusion: Acute episodes of DM-associated hypoglycemia are costly. These episodes also often require hospitalization; the highest costs are incurred by admitted patients with Type 2 DM. More studies are needed to better understand the costs associated with ED use by patients with DM-associated hypoglycemia.
P117: Does an age-adjusted D-dimer threshold provide adequate sensitivity in ED patients investigated for pulmonary embolism?
Authors: Senior K.D. , Burles K. , Grigat D. , Wang D. , Innes G. , Andruchow J. , Lang E. , McRae A.
Published: June 2016

Introduction: The D-dimer assay is a high sensitivity, low specificity test used to rule out pulmonary embolism (PE) in low risk ED patients. Patients with a positive D-dimer result will likely undergo CT imaging to confirm the diagnosis. Given the time, cost, and radiation exposure associated with CT, and the higher false-positive rate in older patients, an age-adjusted D-dimer threshold may be preferred. Our objective was to evaluate the sensitivity and specificity of an age-adjusted D-dimer and approximate the downstream effect on CT imaging utilization. Methods: This was a retrospective cohort study conducted using administrative data from Calgary emergency departments between July 2013 and January 2015. Eligible patients were individuals aged 50 and older who were undergoing PE workup including D-dimer testing. Outcomes were ascertained using CT imaging reports and by searching the regional administrative database for subsequent diagnosis of PE within 30 days of the index visit. These data were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of the D-dimer test using the standard threshold (500 ng/mL) and an age-adjusted threshold (10 ng/mL x patient age as an integer). From this, the potential reduction in CT imaging use and missed PE diagnoses were modeled. Results: Of 6669 patients aged 50 or older who had D-dimer testing for possible PE, 1504 (22.6%) underwent a CT scan, and 217 (14.4% of CT) received a discharge diagnosis of pulmonary embolism, which was confirmed on chart review. When test results were re-interpreted using an age-adjusted threshold, D-dimer specificity increased from 63.9% to 75.4%, while sensitivity decreased from 96.5% to 89.9%. This translates to 888 new true negatives, representing CT scans potentially avoided (a 59% reduction in CT utilization), but with 18 new missed PE diagnoses. Conclusion: The age-adjusted threshold may reduce use of CT imaging among older patients suspected of PE, but at the cost of more missed PE diagnoses.
P120: Exploring the utility of the Hamilton early warning score at triage: pilot study in a Canadian emergency department
Authors: Skitch S. , McInnis L. , Vu A. , Tam B. , Xu M. , Fox-Robichaud A.
Published: June 2016

Introduction: Early warning scores (EWS) use vital signs to identify patients at risk of critical events as defined by unplanned intensive care unit (ICU) admission, cardiopulmonary resuscitation (CPR), or death. Systems that combine an EWS with a ICU outreach team can improve hospital survival and cardiac arrest rates. Although initially developed for use in ward patients, evidence suggests that EWS are useful in emergency department (ED) patients and may aid in the earlier identification of sepsis. The Hamilton Early Warning Score (HEWS) was recently developed as part of quality improvement process in our health system. The current study examined HEWS at ED triage among a cohort of patients who experienced a critical event during their hospitalization. HEWS were also evaluated as a predictor of sepsis. Methods: Patient were selected from a database of patients admitted to a medical or surgical ward at two tertiary care hospitals over a six-month period. Cases were patients who experienced a critical event during admission and were admitted via the ED. Controls were randomly selected from the database in a two-to-one ratio using an algorithm to match cases based upon burden of comorbid illness. Receiver operator curves (ROC) and likelihood ratios were used to evaluate HEWS at ED triage as a predictor of likelihood of critical deterioration and sepsis. Results: The sample included 845 patients of whom 267 experienced a critical event. The median time to occurrence of critical event from admission was 124 hours. ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting likelihood of experiencing a critical event 0.63 [95%CI: 0.58-0.67]. HEWS had fair discriminative ability for predicting likelihood of meeting criteria for sepsis 0.75 [95%CI: 0.71-0.80], and good discriminative ability for predicting likelihood of experiencing a critical event among patients meeting criteria for sepsis 0.80 [95%CI: 0.74-0.86]. Conclusion: This retrospective study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. This may be because deterioration commonly occurred days after admission. However, HEWS may have utility as tool for aiding earlier identification of critically ill septic patients. Prospective studies are needed to further delineate the utility of the HEWS in the ED.
P128: Patterns of injurious falls on snow and ice in public pedestrian areas
Authors: Sugie J. , Brison R.J.
Published: June 2016

Introduction: Maintenance of public pedestrian walkways to ensure safety can be onerous during Canadian winters. The costs of maintenance should be weighed against the potential for reducing injuries related to falls. Ice and snow covered surfaces can increase the chance of falling by 3.5 times compared to normal concrete surfaces. The objectiveof this study is to examine patterns of injury occurrence in persons injured when falling due to snow or ice in public areas. Methods: We identified persons presenting to emergency departments in Kingston, ON for treatment of injuries related to falls on ice or snow for a 5 year period ending in March 2015 using data from the Canadian Hospital Injury Reporting and Prevention Program(CHIRPP). Within CHIRPP, there is a series of variables that describes the injury event, location and circumstances. Hospital medical records were reviewed for additional information on anatomic injuries sustained and subsequent use of hospital based resources.Variables were managed and assessed in Excel. A descriptive analysis examined distributions of variables by subgroups of injury occurrence. Results: 674 injury cases of falls on snow and ice were identified. 316 cases (46.9% of cases/ about 60 per year) occurred in public pedestrian areas, the group of primary interest. Of these: 88 cases (27.8%) resulted in fractures; 68 (21.5%) were soft tissue injuries; 46 (14.6%) were head injuries, concussions or intracranial injuries; and 40 (12.7%) were sprains or strains. Of the fractures, 37 (42.0%) involved the upper limb and 33 (37.5%) involved the lower limb. 72 (81.8%) of fractures were managed in the emergency department with orthopedics referral or follow up. The large majority of sprains or strains (85.0%), soft tissue injuries (80.9%) and head injuries (82.6%) were managed in the emergency department without plans for hospital based follow up. Conclusion: Falls on snow and ice frequently occur on public pedestrian areas. The resulting injury can be significant, leading to fractures in upper and lower limbs. These fractures require more use of hospital based resources than other injury types. It is hoped that providing municipal decision makers with information on the frequency and severity of these injuries will lead to improved snow and ice removal in public pedestrian areas.
P130: Incidence and characteristics of ventricle fibrillation in patients with ST-elevation myocardial infarction in a suburban pre-hospital setting
Authors: Tanguay A.B. , Lebon J. , Bégin F.
Published: June 2016

Introduction:Background: Ischemic ventricular fibrillation (VF) is highly related to ST elevation myocardial infarction (STEMI). Pre-hospital STEMI patients have been shown to also develop VF during ambulance transport. However, there is limited literature exploring the characteristics of this specific population of VF. Objective: To determine the incidence of pre-hospital VF, and evaluate some demographic and electrocardiogram (ECG) characteristics of STEMI patients having VF while transported by ambulance in a Quebec suburban pre-hospital setting. Methods: A retrospective study from 8th August 2006 to 6th December 2015 of 937 STEMI patients transported by ambulance in the Chaudiere-Appalaches region, south of Quebec City. Destination for treatment was either Catherization Laboratory (CL) or the nearest Emergency Department (ED) for reperfusion treatment and was mainly based upon a maximum transport time of 60 minutes, from the first confirmed STEMI-ECG to the CL. Demographics and ECG characteristics were extracted from the patients care records. SPSS-20 was used for descriptive statistics. Results: 937 patients (259 women & 678 men) diagnosed with STEMI were included in the study. Patients were regrouped in V1-V4 leads STEMI (336; 35.9%) and in other leads STEMI (651; 64.1%). 52 (5.55%) of all STEMI patients had FV during ambulance transport. There were 10 women (27,4%) and 42 men (72,6%). Of these, 28 had V1-V4 STEMI (28/336; 8.33%) while 24 had other leads STEMI (24/651; 3.69%). Relative risk of FV is higher (225%) with V1-V4 STEMI compared to other leads STEMI. Regarding age groups, patients from 60 to 70 years old represent 38.4% (20/52) of FV for 25.7% (241/937) of STEMI patients while those over 80 years old had 3.85% (2/52) of FV, but were 17% (159/937) of all STEMI patients. Men seem also more at risk for FV (16/20) especially between 60 and 70 years old compare to other age group. Conclusion: In this suburban area, VF occurred in 5.55% of STEMI patient’s transported by ambulance. STEMI patients over 80 years old had a low rate of FV. Being a man, 60 to 70 years old, with a STEMI located in V1-V4, seems to be associated with a higher risk of VF. More studies are needed to confirm these results and explore other characteristics associated to pre-hospital VF.
P137: Emergency department discharge information sheets - a prescription for success?
Authors: VandenBerg S.D. , Ruhl G. , Lang E.
Published: June 2016

Introduction / Innovation Concept: Effective communication between health providers and patients is central to patient safety, health education and patient empowerment. Previous studies in the Calgary Zone demonstrated that less than fifty percent of emergency department patients thought discharge handouts communicated health information well and even fewer thought the handout information would aid them in care at home. A partnership between the Department of Information Design, Mount Royal University and the Department of Emergency Medicine, University of Calgary, seeks to provide an innovative solution to this problem. Methods: The Calgary Zone Department of Emergency Medicine has partnered with the Mount Royal University Department of Information Design community service learning course. Information design students will work to develop infographics based on the “Choosing Wisely Alberta” Campaign Topics, with content expertise provided by the Department of Emergency Medicine. Curriculum, Tool, or Material: The five “Choosing Wisely Alberta” topics are: CT scans for adults with head injuries, CT scans to find Blood Clots in the lung, Imaging Tests for Headaches, Imaging tests for lower back pain, Treating Sinusitis. The target audience for the project will involve staff physicians, patients, public and government. Student involvement will direct their individual projects to these target audiences and will consider important issues such as non-English speaking patients, patients with low health-literacy (marginalized populations) and “super-users” of emergency departments, health policy (government and not-for-profit), physicians (emergency and primary care) and other health care workers. Infographics will be available for presentation at CAEP 2016. Conclusion: Information graphics will be used to facilitate clinician-patient discussions for empowered decision making, facilitate clinician-learner decisions based on evidence based guidelines, and improve knowledge translation for health system administrators and policy makers regarding appropriate emergency department resource allocation.
P140: Emergency department decision-making for incapacitated and unrepresented patients: a comprehensive review of the literature
Authors: Willinsky J.L. , Hyun I.
Published: June 2016

Introduction: Incapacitated patients who lack substitute decision-makers (SDM) are commonly encountered in the emergency department (ED). The number of these patients will rise dramatically as the Baby Boomers age. We can expect an influx of elderly patients who lack decisional capacity due to dementia and other illnesses, and who present without family. It is estimated that 3 to 4 percent of U.S. nursing home residents have no SDM or advance directives. Medical decision-making for this cohort poses an ethical challenge, particularly in the ED setting. Methods: A comprehensive review of the literature was conducted surrounding decision-making for incapacitated and unrepresented patients in the hospital setting. Articles were identified using MEDLINE (1946-October 2015) and Embase (1974-October 2015). The reference lists of relevant articles were hand searched. Articles describing decision-making processes that have been proposed, tested or applied in practice were chosen for full review. The aim of this review was to outline recognized medical decision-making processes for incapacitated and unrepresented patients, and to identify areas for future research. Results: The search yielded 20 articles addressing decision-making for incapacitated and unrepresented patients in the hospital setting. All of these articles focus on the intensive care unit and other hospital wards; no literature on the ED setting was found. Five types of formal consulting bodies exist to assist physicians in applying the best interest standard for this patient cohort: internal hospital ethics committees, external ethics committees, public guardians, court-appointed guardians, or judges. The majority of decisions for these patients, however, are made informally by a single physician or by a healthcare team, although it is well recognized that this approach lacks appropriate safeguards. There is no consensus surrounding the optimal approach to decision-making in these cases, and as such there is significant inconsistency in how medical decisions are made for these patients. Conclusion: There are several articles describing decision-making processes for incapacitated and unrepresented patients, none of which focus on the ED. These processes are not practical for use in the ED. Further inquiry is needed into the most ethical and respectful method of decision-making for this patient cohort in the ED.
P147: International scope of emergency ultrasound: barriers to utilizing ultrasound to guide central venous catheter placement by providers in Kenya
Authors: Zaver F. , Boniface K. , Shokoohi H. , Wachira B. , Wanjiku G.
Published: June 2016

Introduction: While ultrasound (U/S) use for internal jugular central venous catheter (CVC) placement is standard of care in many institutions in North America, most developing countries have not adopted this practice. Previous surveys of American physicians who are not currently using U/S to place CVCs have identified lack of training and equipment availability as the most important barriers to the use of U/S. We sought to identify Kenyan physicians’ perceived barriers to the use of U/S to guide CVC insertion in a resource-constrained environment. Methods: The study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Physicians participating in a one-hour course teaching U/S guided CVC placement were asked to complete a survey before beginning training, which was used to assess previous experience with U/S, and evaluate perceived barriers to U/S. Survey responses were analyzed using summary statistics and the Rank-Sum test to compare the difference between participants’ responses based on different specialty, gender and previous history of using U/S. Results: There were 23 physicians who completed the course and the survey. They included 6 internal medicine, 5 critical care, 5 anesthesia, 2 emergency medicine and 5 physicians from other specialties. The mean length of practice was 5 years. 52% (95% CI: 0.30-0.73) had put in >20 CVCs. 21.7% (95% CI: 0.08-0.44) of participants had previous U/S training, but none have received any training on the use of U/S for CVC insertion. The respondents expressed agreement on the ease of the use, improved success rate, and decreased failure rate with U/S guidance. However, less agreement was found regarding the perceived superior convenience and cost effectiveness of U/S CVC placement (see Figure). The lack of training or comfort with the U/S and the availability of U/S and equipment to maintain sterility were reported as the main barriers for use. Neither previous U/S experience nor specialty of the respondent significantly affected responses. Conclusion: Barriers to the use of U/S guidance for the placement of CVCs in Nairobi, Kenya are similar to those found among American physicians. These include training and comfort level with U/S in placement of CVCs, as well as resources required for U/S equipment and to keep the field sterile.
PL002: A randomized controlled trial on oral analgesic utilization for children presenting with a musculoskeletal trauma in the emergency department
Authors: Le May S. , Ali S. , Plint A. , Mâsse B. , Neto G. , Auclair M. , Gouin S.
Published: June 2016

Introduction: Background: A single-agent approach to children’s moderate to severe pain is often inadequate. To date, no studies have evaluated the combined use of oral morphine and ibuprofen for optimal pain management of children presenting to an Emergency Department (ED) for musculoskeletal (MSK) trauma. Objective: To assess the efficacy of a combination of oral morphine and ibuprofen for pain management in children with MSK trauma in the ED. Methods: A double-blind, placebo-controlled, multi-centered, three-arm, randomized clinical trial of 500 patients was conducted at three pediatric tertiary care EDs. Patients 6 to 17 years of age, who presented to the ED with a MSK trauma, and a score >30 mm on the 100 mm Visual Analogue Scale were eligible to participate. Patients were randomized (in a 2:1:1 ratio) to receive (orally): (a) morphine (0.2mg/kg) + ibuprofen (10mg/kg) (Group MOR + IBU) or (b) morphine (0.2 mg/kg) + placebo (Group MOR) or (c) ibuprofen (10mg/kg) + placebo (Group IBU). Primary outcome was pain intensity score under 30 mm (mild pain) at 60-minutes (T-60) after treatment administration. Results: A total of 456 patients were included in analyses: 177 (MOR + IBU), 188 (MOR), 91 (IBU). Mean age was 11.9 + 2.7 years, with a majority of boys (55.3%) and soft tissue injuries (62%). There were no differences in baseline characteristics in the three groups. Baseline mean pain score was 60.9 + 16.2 mm. Only 30% (MOR + IBU), 29% (MOR) and 30% (IBU) of patients reached a pain score under 30 mm at T-60 (p=0.83). Mean pain scores at T-60 were 42.3 + 23.2 mm (MOR + IBU), 43.8 + 23.1 mm (MOR) and 42.3 + 23.3 mm (IBU) (p=0.83). No severe adverse events were observed in any of the groups, at any of the study measurement points. Conclusion: Combination of morphine with ibuprofen did not provide any additional pain relief for children with MSK injuries, in the ED. None of the study medication provided optimal pain management, as the majority of children did not reach the WHO definition of mild pain. Alternative analgesic combinations should be investigated to optimize pain relief of children who present to the ED with MSK injuries.
LO003: Outpatient referrals from the emergency department - a retrospective review
Authors: Prudhomme N. , White S. , Kwok E.S.
Published: June 2016

Introduction: While a majority of patients presenting to the emergency department (ED) are discharged home without need for inpatient hospitalization, many require outpatient follow-up. Currently, outpatient referrals from our ED are made via a complex and error-prone series of manual steps which have the potential to be unreliable and negatively impact quality of care. We sought to perform a current state analysis of our outpatient referral processes across the hospital’s specialties. Methods: We conducted a retrospective health records review at a tertiary academic centre (>160,000 ED visits/year) from January 1 to January 7, 2015. All consecutive outpatient consultation requests triggered by an ED physician were identified and included for chart review. All cases were subsequently followed up to 11 months. A single reviewer extracted data on demographics, actual referral attendance rates, incomplete referrals, return ED visits, and time intervals. The top 3 and bottom 3 performing services were identified for further analysis of their outpatient referral mechanisms and processes. We present descriptive statistics. Results: A total of 251 outpatient referrals to a broad range of specialty services were identified during the study period. 216 (86.1%) of patients attended the intended appointment, while 35 (13.9%) of referrals were incomplete at 11 months post index ED visit. The overall median time to successful outpatient follow-up appointments was 8.5 days [IQR=3.8-24.2]. 8 (3.2%) patients had a return ED visit for a related complaint prior to being seen at their outpatient appointment. The top 3 performers were Ophthalmology [Median=1.0 day, IQR=0.0-1.0, Incomplete=2.8%], Plastic Surgery [Median=5.0 days, IQR=2.8-6.0, Incomplete=7.7%], and Orthopedics [Median=8.0 days, IQR=7.0-10.0, Incomplete=0.0%]. The bottom 3 performers were Dermatology [Median=52days, IQR=41.5-92.5, Incomplete=25.0%], Neurology [Median=40.0 days, IQR= 2.5-43.5, Incomplete=56.3%], and Urology [Median=14.0 days, IQR=10.5-48.0, Incomplete=33.3%]. Conclusion: We found a tremendous range of variability in both the waiting times and actual reliability of outpatient referral processes from the ED. Future phases of this project will focus on examining specific processes of the top and bottom performing specialties in order to improve and standardize all outpatient referrals.
LO008: Assessment of the need for diagnostic imaging in extremity injuries by advanced care paramedics
Authors: Froese P. , Butler M.B. , Campbell S.G. , Magee K. , Mackinley R.P.
Published: June 2016

Introduction: Emergency department (ED) crowding is a national challenge. Initiatives to help address this at our ED include the use of a six-bed fast-track unit staffed by advanced-care paramedics (ACPs). Institutional byelaws only allow diagnostic imaging (DI) ordering by physicians (MD). An ACP requesting DI at the time of first assessment would likely improve patient flow. We investigated whether ACPs can safely and cost-effectively request DI for extremity injuries without increasing cost or exposing patients to unnecessary radiation. Methods: A prospective evaluation of a convenience sample of patients presenting with an extremity injury sustained within 48 hours of presentation. At time of initial assessment, the ACP, following specific guidelines, recorded whether or not they believed an x-ray was indicated, and if so, what DI views they felt appropriate. Their opinion was blinded from the physician subsequently assessing the patient. An ACP opinion of the need for DI was compared with the subsequent test ordered by the MD. The MD decision to order DI was considered ‘gold standard’. Opinions were considered “matched” if the MD ordered DI of the same body part that the ACP believed was indicated. Sensitivity, specificity, positive predictive and negative predictive values (PPV, NPV) were calculated. Using data from our ED information system, we estimated the time that would have been saved by allowing ACPs to order DI. Results: Of 199 patients 192 images were ordered and 89 fractures were diagnosed. ACPs and MDs agreed that DI was necessary 94.70% of the time (95% CI: {90.6%, 97.4%}). There were 8 x-rays the ACP did not order that the MD did order, of which one showed a fracture. Twice, the ACP would have ordered an x-ray that the MD did not. In terms of identifying the need for DI, ACPs were 95.8% sensitive and 71.4% specific. The PPV was 98.9% (95% CI: {95.8%, 99.8%}), and the NPV was 38.5% (95% CI: {15.1%, 67.7%}). On average, ACP opinion of DI indication was made 54.1 minutes (95% CI: {48.0, 60.2}) earlier that of the MD. Conclusion: The overall agreement between MDs and ACPs was almost 95%. ACPs are more likely to under-order x-rays than to over-order them, lowering the risk of increasing radiation exposure and cost. ACP DI ordering may decrease the time of processing of patients with extremity injuries by almost an hour.
LO009: Impact of physician navigators on measures of emergency department efficiency
Authors: Leung A. , Gong Z. , Chen B. , Duic M.
Published: June 2016

Introduction: The Physician Navigator (PN) is a novel position created to manage patient flow in real-time at a very-high volume emergency department (ED). When paired with an emergency physician, PNs actively track patient wait times, and direct the physician to see and re-assess patients in a particular order to improve measures of emergency department efficiency, and maximize patient flow. Anecdotal evidence has shown that PNs decrease length-of-stay times for non-resuscitative patients in the setting of increased patient volumes, and without additional nursing or physician hours. The objective was to study the operational impact of PN on emergency department patient flow. Methods: A 48-month pre-/post-intervention retrospective chart review at an urban community emergency department from September 2011 to September 2015. The PN program started on March 1, 2013. The main outcome is emergency department length-of-stay (LOS). Secondary outcomes include time to physician-initial-assessment (PIA), left-without-being-seen rates (LWBS), left-against-medical-advice (LAMA), and physician satisfaction rates. Autoregressive integrated moving average models were generated for Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether the impact was sustained over time. Results: Interim results are provided. 399,958 patients attended the ED during the study period. Daily patient volumes increased 11.2% during the post-intervention period. There were no significant increases in the number of physicians shifts/day, and physician hours/day during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.04 hours/PN (p<0.05), and 90th-percentile LOS by 0.14 hours/PN (p<0.05). For secondary outcomes, there was a decrease in overall average PIA by 6.37 minutes/PN (p<0.05), and 90th-percentile PIA by 8.29 minutes/PN (p<0.05). LWBS rates decreased by 40.8% (p<0.05). There were no significant changes in LAMA rates. Conclusion: The implementation of Physician Navigators is associated with significant reductions in LOS, PIA, and LWBS rates for non-resuscitative patients at a very-high volume emergency department.
LO011: Identification of mild acute cerebrovascular syndrome (ACVS) in the emergency department: validation of an ACVS clinical classifier to help distinguish mimics
Authors: Votova K. , Penn A. , Harris D.R. , Bibok M. , Lesperance M. , Lu L. , Coutts S.D. , Balshaw R.
Published: June 2016

Introduction: National guidelines (NICE, AHA) for management of Acute Cerebrovascular Syndrome (ACVS) in the Emergency Department (ED) recommend the use of ABCD2 score to risk stratify patients despite its poor specificity and low diagnostic accuracy. The SpecTRA project previously developed a clinical classifier for ACVS vs. Mimic derived from historical clinical data collected during a 5-year period at an outpatient stroke clinic (Victoria, BC). Here we present a prospective evaluation of the performance of our clinical classifier on prospectively collected ED patient data compared to the industry-standard ABCD2. Methods: The prospective cohort consisted of ED patients (N=555, Male=54%, Mean (SD) Age=68.7(15.5), ACVS=70%) enrolled between Jan 2014 and May 2015 at Victoria General Hospital (BC) and Foothills Medical Centre (Calgary, AB). ABCD2 and clinical classifier scores were calculated from clinical data from the ED. We compared the performance of the two classifiers using DeLong’s test of Dependent Receiver Operating Curves (ROC). In keeping with national guidelines, we used a score of 4 or more to assess sensitivity, specificity and accuracy (sens/spec and acc) of the ABCD2; for our clinical classifier, we used the cut point previously determined to maximize agreement between predictions and true class labels in the historical data. Results: Our new clinical classifier significantly outperformed the ABCD2 (z=2.44, p=0.015) with an AUC of 0.72, (95% CI: 0.68, 0.77) vs. 0.66 (0.61, 0.71). In terms of sens/spec and acc, our classifier achieved 0.78/0.55 with acc 71% compared to 0.75/0.46 with acc 66% for the ABCD2 (using the previously specified cut points). Conclusion: Our ACVS clinical classifier showed better performance than the ABCD2 score on a prospective sample of ED patients. The improved specificity of the clinical classifier relative to existing prognostic tools would reduce the number of non-ACVS patients referred for early treatment as well as conserve medical resources. Our ongoing multi-site study will evaluate the utility of the ACVS classifier embedded in a logic-enabled e-fillable form. This form will also provide risk-based thresholds guiding timely ordering of CTA as well as links to clinical treatment guidelines. Longer-term, the e-form and classifiers will be further enhanced to include plasma-based protein biomarker data.
LO012: High-risk investigation findings for symptomatic carotid disease in ED TIA patients
Authors: Motamedi N. , Abdulaziz K. , Sharma M. , Perry J.J.
Published: June 2016

Introduction: About 20% of TIAs are due to large vessel disease. Carotid stenosis >50% which is causing a TIA or stroke needs to be definitely managed quickly in order to benefit. Alternatively, dual antiplatelet therapy may be considered. The objective of this study was to determine high-risk diagnostic findings associated with symptomatic carotid disease in ED patients with TIA to indicate patients requiring urgent carotid imaging. Methods: We performed a prospective Canadian multicenter cohort study, at 13 academic sites, of ED patients with TIA or non-disabling stroke from 2006-2014. Study research nurses recorded imaging findings on standardized data collection forms from the final reports of all imaging tests ordered in the ED on prospectively enrolled patients by treating emergency physicians. Symptomatic carotid disease was defined as carotid stenosis 50-99% or carotid dissection and was adjudicated by stroke neurology to be the etiology of the index event. Patients were followed by medical review and telephone up to 90 days. Univariate analysis was conducted for investigation results with our primary outcome. Results: The cohort included 305 patients with and 5,277 without symptomatic carotid disease. Positive predictors of symptomatic carotid disease included platelet count over 400 x 109/L (15.3% vs 7.6%; p=0.0095), blood glucose >15 mmol/L (11.4% vs 4.4%; p<0.0001), CT evidence of acute infarction (9.8% vs 4.1%; p<0.0001), CT evidence of old infarction (35.7% vs 24.1%; p<0.0001), and CT evidence of any infarct (43.3% vs 26.7%; p<0.0001). There were no negative predictors of symptomatic carotid disease. Conclusion: High-risk investigation findings suggestive of symptomatic carotid disease in ED TIA patients include platelet count over 400 x 109/L, blood glucose >15 mmol/L, CT evidence of any infarction. Patients with any of these findings should be considered for rapid carotid imaging.
LO014: What ultrasonography characteristics predict surgical intervention for testicular torsion in adults?
Authors: Ritcey B.W. , Woo M. , McInnes M.D. , Watterson J. , Perry J.J.
Published: June 2016

Introduction: Testicular torsion is a time sensitive condition for which there can be significant delays to surgery or transfer to definitive care while trying to obtain an ultrasound to confirm the diagnosis. This study determines the test characteristics for each individual sonographic sign of testicular torsion associated with the patient requiring surgical intervention. Methods: A retrospective health records review of adult patients with acute, non-traumatic scrotal pain or swelling (defined as under 24 hours since onset) presenting to one of two Canadian academic tertiary care emergency departments between November 2009 and March 2013 was performed. A single data abstractor completed a case report form for each patient including demographics, individual ultrasound findings, final diagnosis, and need for surgical intervention. The sensitivity and specificity of each ultrasonographic sign (including testicular heterogeneity, decreased colour doppler, and decreased pulsed wave doppler) at predicting surgical intervention during the same hospital visit was calculated along with 95% confidence intervals. Results: During the study period there were a total of 876 emergency department visits for scrotal pain, of which 198 patients met our inclusion criteria. The included patients had a mean age of 36.2 years. Decreased blood flow to the painful testicle on colour doppler showed the best overall test characteristics with a sensitivity of 82.4% (95% CI 55.8%-95.3%) and specificity of 100% (95% CI 96.3%-100%) for predicting a need for surgical intervention for testicular torsion. Other ultrasound findings for testicular torsion included a heterogeneous appearance of the painful testicle (sensitivity 47.1% [95% CI 23.9%-71.5%], specificity 77.4% [95% CI 68.9%-84.2%]), and decreased arterial or venous flow on pulsed wave doppler (sensitivity 76.5% [95% CI 49.8%-92.1%], specificity 100% [95% CI 96.3%-100%]). Conclusion: Decreased blood flow to the painful testicle on colour doppler showed excellent specificity and can rapidly “rule-in” a need for surgical intervention for testicular torsion. Given that colour doppler is relatively easy to learn and perform, future studies should assess the use of colour doppler using point of care ultrasound to expedite surgical consultation.
LO015: A multi-centered regional emergency department study of renal colic management using medical expulsion therapy
Authors: Bristow E. , Kinnaird A. , Schuler T. , Pang P. , Couperthwaite S. , Villa-Roel C. , Rowe B.H.
Published: June 2016

Introduction: Patients with renal colic present frequently to the emergency department (ED). Existing literature suggests management with medical expulsion therapy (MET) may improve outcomes, especially for those with stones > 5 mm in size. This study evaluates the use of MET in the management of adult patients seen in regional EDs with a diagnosis of renal colic. Methods: A multi-centered medical chart review study was conducted in seven Edmonton-Zone EDs. Approximately 100 cases from each site were randomly selected from administrative data from the 2014 calendar year, no repeat cases were permitted. Using a standardized data collection process and trained research assistance, data were abstracted from medical charts. Medians and inter-quartile ranges (IQR), proportions, and odds ratios (OR) with 95% confidence intervals (CIs) are reported. Results: Overall, 656 patient charts were included in the review; median age was 46 years (IQR: 35, 46) and 249 (38%) were female. Few (10%) arrived by ambulance or were on MET therapy at presentation; however, many (51%) reported a previous episode of renal colic. Many (191 {29%}) received no initial ED imaging; CT (236 {36%}) was favoured over ultrasound (39 {6%}) for initial imaging, either alone or with plain radiographs (8%). Plain radiographs were frequently ordered (204 {31%}). Only 198 (31%) of charts contained documentation of the use of MET at discharge and the median duration of therapy was 10 days (IQR: 7, 14). Initiation of MET therapy did not vary based on older age (OR = 0.8; 95% CI: 0.57, 1.14); sex (OR = 0.9; 95% CI: 0.67, 1.33); resident involvement (OR = 1.1; 95% CI: 0.63, 2.0); presentation to an academic centre (OR = 1.4; 95% CI: 0.96, 1.95) or stone size (OR = 1.3; 95% CI: 0.76, 2.06). Conclusion: Management of renal colic with MET is uncommon in this region and practice variation appears driven by physician preference rather than evidence. Practice guidelines with standardized order sets are urgently needed to improve care.
LO017: Review of prehospital naloxone use in Ontario: Is a mandatory patch point necessary?
Authors: Charbonneau V. , Costain N. , Austin M. , Willmore A. , Reed A. , Maloney J. , Lewis J. , Vaillancourt C. , Dionne R.
Published: June 2016

Introduction: Recent years have brought an epidemic of opioid abuse to Canada. At present, in Ontario, Naloxone may not be administered by any paramedic without the direct online medical approval of a Base Hospital Physician (BHP). The objective of this study was to review the use of Naloxone by Emergency Medical Service (EMS) personnel, under the existing Advanced Life Support Patient Care Standards (ALS-PCS) medical directive for opioid toxicity, for safety and potential complications that may occur with removal of the mandatory patch point. Methods: This study was a retrospective ambulance call report review of consecutive Naloxone requests placed to a BHP of the Regional Paramedic Program of Eastern Ontario (RPPEO) between Oct 1st, 2013 and Oct 31st, 2015. The RPPEO consists of 10 prehospital services, both urban and rural jurisdictions, and has a mix of advance care and primary care paramedics. All ambulance call reports are electronically stored at the secured RPPEO data warehouse. Data was extracted using a standardized data collection tool. All ambulance call reports were reviewed by 2 independent authors (VC, NC). Compliance with the existing medical directive for opioid toxicity was determined. We calculated the frequency of denied Naloxone requests and the rationale for each patch refusal was recorded. We also categorized all adverse events associated with Naloxone administration. Results: From 244 patches, 215 patients were administered Naloxone. Only 7.8% (19/215) of requests for Naloxone were refused; 78.9% (15/19) did not meet existing inclusion criteria for Naloxone administration in the ALS-PCS medical directive for opioid toxicity because the patient’s respiration rate was above 12/min. Of the 215 patients who were administered Naloxone, adverse events were extremely uncommon: 5 (2.3%) became violent or verbally abusive, 1 (0.5%) was transiently hypertensive and 4 (1.9%) vomited. Conclusion: Requests for Naloxone to a BHP are common and yet are seldom declined. The use of prehospital Naloxone is associated with few adverse events. These results demonstrate that it would be safe to remove online medical direction for Naloxone from the ALS-PCS medical directive for opioid toxicity if combined with updated paramedic education.