bluuebunny/crossref_metadata_2025 huggingface dataset:
P046: Students as first responders: A survey of Canadian campus emergency medical response teams
Authors: Formosa E. , Grainger L. , Roseborough A. , Sereda A. , Cipriano L.
Published: May 2019

Introduction: Canadian post-secondary campuses are densely-populated communities and the first home-away-from-home to many students participating in various academic programs, new social activities, and on-campus athletic activities. The diversity of on-campus activities combined with the high-stress of academic programs results in illness and injury rates that may increase the strain on emergency medical systems. Existing on some campuses for more than 30 years, campus emergency medical response teams (CEMRTs) address the need for a local emergency medical service that can provide first-aid in low-acuity situations and rapid response to high-acuity emergencies. In Canada, many student-run volunteer-responder CEMRTs exist but the range of their service capabilities, operations, and their call-volumes have not been described previously. This study aims to fill this knowledge gap. Methods: We surveyed the 30 known campus emergency medical response teams identified through membership in the Canadian Association of Campus Emergency Response Teams. The 32-question survey asked information on their level of training (standard first aid [SFA], first responder [FR], emergency medical responder [EMR]), service operations including call volume, and funding model. This study was approved by the Western University Institutional Review Board. Results: Twenty-four teams completed the survey (80%); the majority of which are located in Ontario (70%, 16 teams). One team reported that they are no longer in operation. Eleven teams (48%) have medical directors. Nine teams (39%) reported responding to ≤100 calls/year, 11 teams (48%) reported 100-500 calls/year, and 3 teams (13%) reported >500 calls/year. Responders of two teams (9%) maintain training at SFA level; 14 teams (61%) have some or all responders with FR training; and 6 teams (26%) have some or all members certified at EMR level. Twenty-one teams (91%) are equipped with AEDs and 19 teams (83%) are equipped with oxygen. Common medications carried include epinephrine (13 teams, 57%), naloxone (12 teams, 52%), and acetylsalicylic acid (9 teams, 39%). Conclusion: Canadian post-secondary campuses have highly-active student-run volunteer CMERTs. Considerable variability in the services provided may reflect the unique needs of the campuses they serve. CEMRTs may reduce low-acuity case demand on local emergency medical response and emergency department services in some communities; their impact on system demand and costs is the subject of future work.
P048: Current practices of management for mild traumatic brain injuries with intracranial hemorrhage
Authors: Fortier É. , Paquet V. , Émond M. , Chauny J. , Hegg S. , Malo C. , Carmichael P. , Champagne J. , Gariepy C.
Published: May 2019

Introduction: The radiological and clinical follow-up of patients with a mild traumatic brain injury (mTBI) and an intracranial hemorrhage (ICH) is often heterogeneous, as there is no official guideline for CT scan control. Furthermore, public sector health expenditure has increased significantly as the number of MRI and CT scan almost doubled in Canada in the last decade. Therefore, the main objective of this study was to describe the current management practices of mTBI patients with intracranial hemorrhage at two level-1 trauma centers. Methods: Design: An historical cohort was created at the CHU de Québec – Hôpital de l'Enfant-Jésus (Québec City) and Hôpital du Sacré-Coeur (Montréal). Consecutive medical records were reviewed from the end of 2017 backwards until sample saturation using a standardized checklist. Participants: mTBI patients aged ⩾16 with an ICH were included. Measures: The main and secondary outcomes were the presence of a control CT scan and neurosurgical consultation/admission. Analyses: Univariate descriptive analyses were performed. Inter-observer measures were calculated. Results: Two hundred seventy-four patients were included, of which 51.1% (n = 140) came from a transfer. Mean age was 60.8 and 68.9% (n = 188) were men. Repeat CT scan was performed in 73.6% (n = 201) of our patients as 12.5% showed a clinical deterioration. The following factors might have influenced clinician decision to proceed to a repeat scan: anticoagulation (association of 87.1% with scanning; n = 27), antiplatelet (84.1%; 58), GCS of 13 (94.1%; 16), GCS of 14 (75%; 72) and GCS of 15 (70.2%; 111). 93.0% (n = 254) of patients had a neurosurgical consultation and only 6.7% (17) underwent a neurosurgical intervention. Conclusion: The management of mild traumatic brain injury with hemorrhage uses a lot of resources that might be disproportionate with regards to risks. Further research to identify predictive factors of deterioration is needed.
P061: Post-market surveillance of a serious board game: the GridlockED experience
Authors: Hale S. , Chan T.
Published: May 2019

Introduction: In 2016, a team at McMaster began developing GridlockED, an educational (or “serious”) board game designed to teach medical learners about patient flow in the emergency department. As serious board games are a relatively new phenomenon in medical education, there is little data on how marketed games are actually used once received by end-users. In this study our goal was to better understand the demographics and game usage for purchasers of the GridlockED board game, which will inform the further improvement or expansion of the game. Methods: Individuals who expressed interest in purchasing gridlockED via our online storefront were sent an anonymous online survey via Google Form. The survey collected demographic and qualitative data with a focus on the respondent's role in medicine, how they have used GridlockED, who they have played GridlockED with, and what changes or additions to GridlockED they would like to see. We also asked about changes for a potential mass-market version of the game targeted towards non-medical individuals. Individuals who did not purchase the game were asked about their barriers to purchase. We received an exemption for this study from our institutional review board. Results: 42 responses (out of 300 individuals on our mailing list, 14% response rate) were collected. Responding purchasers were from 16 different roles in healthcare and 11 different countries. The top 5 roles were: EM trainee, Community EM MD, Academic EM MD, Physicians from other specialties, and EM program director. The majority of respondents were Canadian (38%), with America (21%), New Zealand (10%), and Turkey (7%) the only other countries to have more than 2 respondents. 50% reported having played the game, with the most common use cases being for fun (76%), for teaching trainees (33%) or training with colleagues (19%). For those who did not purchase, price was the largest barrier (81%). 50% of respondents expressed interest in a disaster scenario expansion pack, with 33% interested in set lesson plans. Conclusion: GridlockED attracted interest from a wide range of medical professionals, both in terms or role and location. Users mainly reported using the game for fun, with fewer users using the game for teaching/training purposes. The main barrier to purchase was the game's price.
P070: Mental health consultations for emergency department patients in crisis: Insights into quality improvement opportunities from a multicenter analysis
Authors: Kelliher B. , Wang D. , Lang E.
Published: May 2019

Introduction: Mental health and addiction presentations are on the increase in Canadian Emergency Departments (EDs) and are placing strains on existing resources. The purpose of this study is to examine practice variations and opportunities for improved mental health (MH) consultation practices across four adult EDs. Methods: We conducted a retrospective analysis of administrative data from Alberta Health Services (AHS) at urban Calgary Zone EDs from 2015 to 2018 regarding MH consults requested and patients admitted to inpatient psych. Individual MD and overall referral rates as well as admission rates for patients consulted to MH were considered. Time of day and patient ETOH level were also examined as potential influencing factors. CEDIS codes were used to identify MH complaints. Results: 73,536 MH related visits were included, 29,228 received a MH consult with 10,648 admitted to an inpatient MH unit (36.4%). The admission rate among consults requested varied considerably among the 200 MDs who evaluated more than 50 patients with MH complaints; median 35.9%, IQR – 25.0 to 47.5. The average consultation rate for ETOH positive patients was 28.4% median 26.35%, IQR – 21.2 to 35.0% During regular working hours (08:00-17:00), there were 33,599 MH visits, 15,035 received a psych consult with 5,976 admitted to an inpatient MH unit. The admission rate among consults was 39.8%. For the remaining hours(17:01-07:59) there were 39,939 MH visits, 14,191 received a psych consult with 4,672 admitted to an inpatient MH unit. The admission rate among consults was 32.9%. Conclusion: Varying MD thresholds for MH consultation are reflected in a wide range of admission rates among patients consulted for MH evaluation in the ED. ETOH and timing of presentation are factors which modulate the likelihood of admission. There may be opportunities to improve MH referrals from the ED by providing consultation feedback to providers.
P072: Comparing met vs. unmet palliative care needs in patients with end-stage conditions presenting to two Canadian emergency departments
Authors: Garrido Clua M. , Kruhlak M. , Kirkland S. , Villa-Roel C. , Elwi A. , O'Neill B. , Brisebois A. , Duggan S. , Rowe B.
Published: May 2019

Introduction: Patients with end-stage conditions require integrated physical, spiritual, psychological and social care. Despite efforts to provide comprehensive community care, those with severe symptoms often present to emergency departments (EDs) with palliative care (PC) needs. The objective of this study was to identify patients with end-stage diagnoses presenting to EDs, and to document and compare their PC needs. Methods: A four-month prospective cohort study was conducted in two Canadian EDs. Using a modified PC screening tool, volunteer emergency physicians identified adult patients with end-stage illnesses and documented their PC needs. This tool has the ability to classify patients as having met vs. unmet PC needs based on the documentation of risk factors. Research assistants documented demographic information, severity at presentation (Canadian Triage and Acuity Scale {CTAS}), disposition and revisits from an electronic repository. Bivariate comparisons between patients with met vs. unmet PC needs were completed. Results: Overall, 663 patients were enrolled, of which 78% (n = 518/663) were identified as having unmet PC needs according to the screening tool. Cancer was the most prevalent condition in each group (43% unmet needs, 37% met needs). There was no significant difference between the two groups in terms of age, sex or CTAS score. The unmet PC needs group was more likely to be admitted (68% vs. 50%; p = 0.0001) when compared to patients with PC needs assessed as being met. No significant difference was noted in terms of time to physician assessment or ED length of stay. The two groups did not significantly differ in the proportion of return visits within 30 days (34% vs. 32%) or the average number of return visits (3 vs. 2 visits). A higher proportion of patients with unmet PC needs made at least one visit to the ED in the 6 months prior to their index visit compared to patients with met PC needs (74% vs. 51%, p < 0.001); yet, the average number of ED visits was similar between the groups (3 visits). Conclusion: This study revealed that patients with end-stage diagnoses, especially cancer, commonly have unmet PC needs. They are also more likely to present to the ED and to require hospitalization than patients in whom PC needs have been met. Further investigations into their clinical profile and health care utilization may clarify the impact of their unmet PC needs on the healthcare system.
P074: Improving urology care in the emergency department through implementation of an Acute Care Urology model
Authors: Kirubarajan A. , Buckley R. , Khan S. , Richard R. , Stefanova V. , Chin A. , Golda N.
Published: May 2019

Introduction: Renal colic is one of the most common presentations to the emergency department (ED), and often requires complex interdisciplinary collaboration between emergency physicians and urology surgeons. Previous literature has shown that adoption of interdisciplinary rapid referral clinics can improve both timeliness of care and patient outcomes. However, these Acute Care Surgery models have not yet been commonly adopted for urology care in the ED. Methods: In July 2016, we adopted the intervention of an Acute Care Urology (ACU) model through the creation of a rapid referral clinic dedicated to ED patient referrals, the addition of an ACU surgeon, and enhanced use of daytime OR blocks. We conducted a manual chart review of 579 patients presenting to the ED with a complaint of renal colic. Patient data was collected in two separate time periods to analyze trends before implementation of the ACU model (pre-intervention, September - November 2015), to examine the model's impact (post-intervention, September - November 2016). Secondary methods of evaluation included a survey of 20 ED physicians to capture subjective feedback through Likert scale data. Results: Of the evaluated 579 patients with a complaint of renal colic,194 patients were discharged from ED with an diagnosis of obstructing kidney stone and were referred to urology for outpatient care. The ED-to-clinic time was significantly lower for those in the ACU model (p <0.001). The mean time to clinic was 15.76 days (SD = 15.47, range 1-93) pre-intervention versus 4.17 days (SD = 2.33, range = 1-12) post-intervention. Furthermore, the ACU clinic allowed significantly more patients to be referred for outpatient care (p = 0.0004). There was also higher likelihood that patients would successfully obtain an appointment following referral (p = 0.0055). Decreasing trends were shown in mean ED wait time, in addition to time from assessment to procedure. Results of the qualitative survey were overwhelmingly positive. All 20 surveyed ED physicians were more confident that outpatients would be seen in a timely manner (85% strongly agree, 15% agree). Qualitative feedback included the belief that follow-up is more accessible, that ED physicians are less likely to page the on-call urologist, and that they are able to discharge patients sooner. Conclusion: The ACU model for patients with renal colic may be beneficial in reducing ED-to-clinic time, ensuring proper follow-up after ED diagnosis, and improving patient care within the ED.
P075: Emergency physicians’ self-reported management of benign headache in Alberta emergency departments
Authors: Krebs L. , Villa-Roel C. , Couperthwaite S. , Ospina M. , Holroyd B. , Rowe B.
Published: May 2019

Introduction: Benign headache (BHA) management varies across emergency departments (EDs). This study documented current BHA management by Alberta emergency physicians (EP) in order to develop a provincial intervention to improve standardized practice. Methods: A convenience sample of Alberta EPs completed an online survey exploring their ED BHA management practices. Results are expressed as proportions. Results: A total of 73 EPs (73/192; 38%) who were mostly male (63%) and practiced emergency medicine for at least 15 years (51%) responded. EPs reported routine ED orders for metoclopramide (97%), ketorolac (90%) and IV fluids (85%) for patients with BHA showing no signs of pathological headache. For moderate-severe BHA's that did not improve with routine treatment, preferences were: IV narcotic (58%), IV dexamethasone (44%), and IV/IM dihydroergotamine (27%). Typically, EPs reported not ordering investigations for moderate-severe BHA presentations (88%); however, for those not improving the most common investigation was computed tomography (CT; 47%). CT ordering was associated with the following clinical scenarios: 1) not responding to traditional therapy and consulted to specialist (64%); 2) not responding to traditional therapy and being admitted (64%); 3) first presentation and afebrile (19%); 4) severe pain (11%); and 5) responding to traditional therapy and febrile (11%). One-quarter of EPs (27%) believed their patients usually or frequently expected a CT. Most EPs (60%) reported being completely or mostly comfortable discussing CT risks. Only 44% reported always or usually discussing risks prior to ordering. EPs reported that they were most frequently prevented from discussing risks because the patient was critically ill (42%) or because they believed explaining risks would not alter patient expectations (21%). These concerns were mirrored in the barriers EPs anticipated to limiting imaging, specifically the fear of missing a severe condition (62%), and patient expectation/request for imaging (48%). Conclusion: Self-reported treatment preferences for uncomplicated BHAs appear to be relatively consistent. Chart reviews could help assessing the reliability of self-reported BHA management practices. Perceived patient expectation appears to be an important influence on EP imaging ordering. Studies examining the communication between EPs and their patients are needed to explore how these expectations and perceived expectations are negotiated in the ED.
P100: A needs assessment to guide the development of multidisciplinary simulation-based modules relevant to emergency department nurses in Newfoundland and Labrador
Authors: Smith S. , Bursey K. , Parsons M.
Published: May 2019

Introduction: Efficient multidisciplinary team dynamics are crucial to the provision of optimal ED care. Physicians and nurses must use a collaborative approach to meet patient needs in this busy setting. This is especially important for high-acuity low-occurrence (HALO) procedures and clinical encounters. Simulation provides a safe environment where learning is enhanced through deliberate practice. Multidisciplinary participation in simulation-based education may augment team cohesiveness and performance. Methods: A web-based needs assessment survey was distributed to ED nurses, collecting information on demographics, opinions about simulation-based instruction and perceptions on the value of the proposed collaborative educational approach of the project. Experience and comfort with nursing roles in specific procedures (TV pacer, surgical airway, chest tube, central line, sedation) and clinical encounters (STEMI, CVA, sepsis, anaphylaxis, GI bleed) seen in the ED were also assessed. There were a number of suggestions for topics in addition to those listed. Responses will guide the collaborative development of simulation modules with nursing colleagues on desired topics. Results: 58/97 potential nurse participants from 2 urban ED's responded to the survey over an 8-week period, giving a response rate of 58.8%. 76% of respondents had less than 10 years of ED nursing experience, and 34.48% less than 5 years. Responses indicate limited familiarity with simulation-based education (SBE) on ED scenarios with 33.93% being not familiar; 55.36% somewhat familiar. Most prior simulation experience was with role-playing (82%) or low-fidelity setups (42%). Perceived benefit of SBE sessions was substantial (43.86%- very significant; 45.61%- significant). Most respondents had limited past exposure (22.81%- none; 64.91%- 1-5 sims). Similarly, there was little ongoing participation in SBE events with none in 43.64% and 40% just annually. For the 5 clinical scenarios, average responses were: Comfort with assisting 87.45%; Interest in further training 91.43%; Willingness to participate 94.13%. For the 5 procedures, averages were 36.35% (21.36% excluding sedation), 91.27%, 89.09%, respectively. Conclusion: Results indicate a low level of familiarity, experience and ongoing exposure with SBE relating to ED training and practice. Participants recognize the potential benefits of using simulation in a multidisciplinary educational setting and indicate a willingness to participate in collaborative teaching sessions.
P106: The HINTS exam: An often misused but potentially accurate diagnostic tool for central causes of dizziness
Authors: Regis A. , LePage R. , Bodunde O. , Turgeon Z. , Ohle R.
Published: May 2019

Introduction: Dizziness is a common presentation in emergency departments (ED), accounting for 2-3% of all visits. The HINTS (Head impulse test, Nystagmus, Test of skew) exam has been proposed as a accurate test to help differentiate central from peripheral causes of vertigo. It is only applicable to patients presenting with acute vestibular syndrome (acute onset dizziness or vertigo, ataxia, nystagmus, nausea and/or vomiting, and head motion intolerance). We aimed to assess the diagnostic accuracy of HINTS in detecting central causes of dizziness and vertigo in adult patients presenting with AVS. Methods: We performed a medical records review of all patients with a presenting complaint of dizziness to a tertiary care ED between Sep 2014 and Mar 2018. We excluding those with symptoms >14days, recent trauma, GCS <15, hypotensive, or syncope/loss of consciousness. Data were extracted by 5 trained reviewers using a standardized data collection sheet. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database to assess for any patients with a missed central cause. The primary outcome measure was a central cause of dizziness; cardiovascular accident (CVA), transient ischemic attack (TIA), brain tumour (BT) or multiple sclerosis (MS) as diagnosed on either computed tomography, magnetic resonance imaging, neurology consult or diagnostic codes within ICES. Results: 3109 patients were identified and 2309 patients met the inclusion criteria, of those 450 patients (44% male) were assessed using HINTS exam. Of those examined with HINTS, 7 patients (1.6% - 4 CVA 2 TIA 1 MS) were determined to have a central cause for their dizziness. HINTS had a sensitivity of 28.6% (95%CI 3.7 – 71%), specificity 95% (95%CI 92.6-96.9%). Of the individuals assessed with HINTS, only 16 presented with AVS (3.6%), of which three patients were found to have a central cause (CVA 2, TIA 1). HINTS in AVS for all central causes is 66.7% (95%CI 9.4-99.2%)sensitive but is 100%(95%CI 15.8-100%) for CVA alone (excluding TIA). Only 38%(16/42) of patients presenting with AVS were assessed using the HINTS exam. Conclusion: The current use of HINTS is inaccurate and it is used inappropriately in a large number of patients. Future studies should focus on the correct implementation of HINTS in the ED only in patients presenting with AVS.
P107: Understanding the sensory experience of performing a rare, high-stakes clinical procedure: a qualitative study of clinicians with lived experience
Authors: Riggs J. , McGowan M. , Hicks C.
Published: May 2019

Introduction: Emergency physicians (EP) are expected to be competent in a variety of uncommon but life-saving procedures, including the bougie assisted cricothyrotomy (BAC). Given the rarity and high-stakes nature of the BAC, simulation is often used as the primary learning and training modality. However, mental practice (MP), defined as the “cognitive rehearsal of a skill in the absence of overt physical movement”, has been shown to be as effective as physical practice in several areas, including athletics, music, team-based resuscitation and surgical skill acquisition. MP scripts incorporate cues from different sensory modalities to supplement instructions of how to complete the skill. We sought to explore EPs perspectives on the kinesthetic, visual and cognitive aspects of performing a BAC to inform the development of a MP BAC script. Methods: We undertook a qualitative interview study of EPs at a single tertiary care centre who had done a BAC in clinical practice. Participants were recruited using purposive sampling. The primary method for data collection was in-depth semi-structured qualitative interviews, which were recorded and transcribed verbatim. Data collection and analysis were concurrent; transcripts were coded independently by two researchers using qualitative content analysis on a coding framework based on the previously developed BAC checklist. At each procedural step, the kinesthetic, visual and cognitive cues that enhance MP were identified. Results: Eight EPs (5 staff; 3 Royal College residents) participated in the interviews. All participants had completed at least one BAC in their clinical practice. Data analysis revealed recurrent themes signifying successful completion of each procedural step. These include visual (ie. seeing a spray of blood upon entry into the airway) and kinesthetic (ie. feel of the tracheal rings on a finger) cues that describe aspects of the procedure not found in traditional teaching modalities, such as textbooks. Conclusion: Knowledge gleaned from the interviews of EPs with lived experience gives us a deeper insight into the sensory aspects of performing a BAC in clinical practice. We expect that using these experientially derived cues to inform the development of a MP script will increase its validity and applicability to learners and for skill maintenance. Future work includes evaluating the utility of the developed script in acquiring and maintaining competence performing the BAC.
P110: Are there differences in student academic and clinical performance after rotations at tertiary or community care Emergency Medicine teaching sites?
Authors: Rotenberg C. , Field S.
Published: May 2019

Introduction: Canadian undergraduate medical Emergency Medicine (EM) rotations are often completed at either tertiary care centres or regional community hospitals. While the latter offer students exposure to different practice settings and population needs, many students perceive that teaching at tertiary care EM departments is superior to that in community hospitals. At our institution, third year undergraduate medical students complete three-week EM rotation at either a tertiary centre or a community hospital. We compared academic and clinical performance between students trained in tertiary care centres and students trained in community hospitals. Methods: Academic and clinical performance in EM was evaluated based on the results of an EM-specific multiple choice examination (MCQE) and an annual Objective Structured Clinical Exam (OSCE) assessing competency in a broad range of clinical scenarios commonly addressed in EM. The 40-question MCQE is administered quarterly and a mix of old and new questions are used to ensure consistency. The OSCE is administered annually and relies on the same principal to remain consistent. OSCE scores are binary: pass or fail. We reviewed MCQE and OSCE scores from three consecutive cohorts of students. Students were pooled into two groups, tertiary and community, based on the site of their EM rotation. Mean MCQE and OSCE performance were compared between the two groups of students using two-tailed unpaired T tests. Chi squared tests were used to identify significant differences in scores between cohorts. Results: MCQE and OSCE scores from 312 students over three consecutive cohorts were analyzed. Cohorts included 104, 100, and 108 students with 61% trained in tertiary centres (N = 191). Students trained in tertiary centres had a mean MCQE score of 77%. Students from community centres had a mean score of 78%. There was no significant difference in MCQE scores between tertiary- and community-trained students (p = 0.6099). The OSCE pass rate was 97% for students trained in tertiary centres and 98% for students trained in community centres. OSCE pass rates were not significantly different between the two groups (p = 0.8145). Conclusion: Despite student perceptions that training in tertiary care EM centres was superior, objective analysis showed that academic and clinical performance were similar regardless of training site.
P120: Characteristics and outcomes of patients with neurologic complaints who have an unscheduled return visit to the emergency department within 72 hours
Authors: Schouten A. , Gauri A. , Bullard M.
Published: May 2019

Introduction: Patients with neurologic presenting complaints comprised 12.5% of total University of Alberta Emergency Department (ED) visits in 2017. This group of patients has high rates of EMS utilization, admission, and ED resources including diagnostic imaging and consult services. We sought to analyze the characteristics and outcomes of the patients with neurologic complaints who have an unscheduled return visit (URV) to the ED within 72 hours to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care System databases to select adult patients presenting to the University of Alberta hospital in 2017 with neurologic complaints as defined by the Canadian Triage and Acuity Scale (CTAS). We additionally selected for return visits to Edmonton Zone EDs within 72 hours. Using standard descriptive statistics, we examined demographic and clinical characteristics of patients with 72-hour URV. Results: Of 8,770 total visits, 674 (7.69%) had a 72-hour URV to an Edmonton zone ED. The URV rate was 9.0% in patients seen by a physician and discharged with approval and 23.4-33.3% in patients who left against medical advice (LAMA), prior to completion of treatment (LPCT), or without being seen by a physician (LWBS). The mean age of URV patients was 45.6 years, 56.5% were male, with a mean ED length of stay of 7.37 hours. The top 5 diagnoses for URV patients were headache, migraine, alcohol related disorders, concussion, and transient ischemic attack. 14.7% of URV patients were admitted, 13.5% LWBS, 1.6% LAMA, 1.6% LPCT, and 66.1% were discharged. Conclusion: The majority of neurologic complaint patients with URV within 72 hours are those who LAMA, LPTC, or LWBS at index visit. The admission rate for URV patients (14.7%) is lower than for the index ED visit (55%), however these patients have high LWBS rates. Identifying strategies to limit the LWBS rate for these patients would reduce return visits and improve the quality and safety of patient care.
P126: Entrepreneurship in healthcare and health education: A scoping review
Authors: Suryavanshi T. , Lambert S. , Chan T.
Published: May 2019

Introduction: Today's emergency department sees healthcare system pressures manifest through longer wait times, increased costs, and provider burnout. In the face of questionable sustainability, there is a greater role for training future innovators and entrepreneurs in healthcare. However, there is currently little formal education or mentorship in these areas. The aim of this scoping review was to identify the current and ideal educational practices to foster innovative and entrepreneurial mindsets, with specific interest amongst emergency medicine trainees. Methods: Using a scoping review methodology, the relationship between healthcare and entrepreneurship was explored. OVID, PubMed and Google Scholar were searched using the keywords “entrepreneurship”, “health education” and “health personnel”, on March 8th, 2018. Results were screened by title, abstract and full text by a team of three calibrated researchers, based upon pre-defined exclusion and inclusion criteria. The final list of papers was reviewed using an extraction tool to identify demographics, details of the paper, and its attitudes and perceptions towards entrepreneurship and innovation. Results: After screening, 59 papers were identified for qualitative analysis. These papers ranged from 1970-2018, mainly from the USA (n = 36). Most papers were commentaries/opinions (n = 35); 11 papers described specific innovations. Entrepreneurship was viewed positively in 45 papers, negatively in 2 papers, and mixed in 12 papers. Common specialties discussed were surgery (n = 9), internal medicine (n = 3), and not specified (n = 44). Emergency medicine was described in one paper. Major themes were: entrepreneurial environment (n = 29), funding and capital (n = 12), idea generation (n = 9), and teaching entrepreneurship (n = 6). Of the 11 innovation papers, the discussion was focused on educational (n = 6) or system (n = 5) innovations. These innovations related to surgery (n = 1), public health (n = 1) and palliative care (n = 1). None of these innovations were specific to emergency medicine. Conclusion: This review indicates a small number of programs focused on promoting innovation and entrepreneurship amongst trainees, but no programs specific to the emergency department. There may be benefit for educators in emergency medicine to consider how to foster a greater innovative spirit in our speciality, so our next generation of physicians can help tackle problems affecting patient care.
PL02: A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with recent-onset atrial fibrillation
Authors: Stiell I. , Perry J. , Birnie D. , Macle L. , Vadeboncoeur A. , Thiruganasambandamoorthy V. , Borgundvaag B. , Brison R. , Hohl C. , McRae A. , Rowe B. , Sivilotti M. , Morris J. , Mercier E. , Clement C. , Brinkhurst J. , Taljaard M. , Wells G.
Published: May 2019

Introduction: For rhythm control of acute atrial fibrillation (AAF) in the emergency department (ED), choices include initial drug therapy or initial electrical cardioversion (ECV). We compared the strategies of pharmacological cardioversion followed by ECV if necessary (Drug-Shock), and ECV alone (Shock Only). Methods: We conducted a randomized, blinded, placebo-controlled trial (1:1 allocation) comparing two rhythm control strategies at 11 academic EDs. We included stable adult patients with AAF, where onset of symptoms was <48 hours. Patients underwent central web-based randomization stratified by site. The Drug-Shock group received an infusion of procainamide (15mg/kg over 30 minutes) followed 30 minutes later, if necessary, by ECV at 200 joules x 3 shocks. The Shock Only group received an infusion of saline followed, if necessary, by ECV x 3 shocks. The primary outcome was conversion to sinus rhythm for ≥30 minutes at any time following onset of infusion. Patients were followed for 14 days. The primary outcome was evaluated on an apriori-specified modified intention-to-treat (MITT) basis excluding patients who never received the study infusion (e.g. spontaneous conversion). Data were analyzed using chi-squared tests and logistic regression. Our target sample size was 374 evaluable patients. Results: Of 395 randomized patients, 18 were excluded from the MITT analysis; none were lost to follow-up. The Drug-Shock (N = 198) and Shock Only (N = 180) groups (total = 378) were similar for all characteristics including mean age (60.0 vs 59.5 yrs), duration of AAF (10.1 vs 10.8 hrs), previous AF (67.2% vs 68.3%), median CHADS2 score (0 vs 0), and mean initial heart rate (119.9 vs 118.0 bpm). More patients converted to normal sinus rhythm in the Drug-Shock group (97.0% vs 92.2%; absolute difference 4.8%, 95% CI 0.2-9.9; P = 0.04). The multivariable analyses confirmed the Drug-Shock strategy superiority (P = 0.04). There were no statistically significant differences for time to conversion (91.4 vs 85.4 minutes), total ED length of stay (7.1 vs 7.7 hours), disposition home (97.0% vs 96.1%), and stroke within 14 days (0 vs 0). Premature discontinuation of infusion was more common in the Drug-Shock group (8.1% vs 0.6%) but there were no serious adverse events. Conclusion: Both the Drug-Shock and Shock Only strategies were highly effective and safe in allowing AAF patients to go home in sinus rhythm. A strategy of initial cardioversion with procainamide was superior to a strategy of immediate ECV.
LO02: Development of the HEARTRISK6 Scale for emergency department patients with acute heart failure
Authors: Stiell I. , McRae A. , Rowe B. , Dreyer J. , Mielniczuk L. , Borgundvaag B. , Yan J. , Sibley S. , Nemnom M. , Clement C. , Brinkhurst J. , Sheehan C. , Perry J. , Taljaard M.
Published: May 2019

Introduction: We previously derived (N = 559) and validated (N = 1,100) the 10-item Ottawa Heart Failure Risk Scale (OHFRS), to assist with disposition decisions for patients with acute heart failure (AHF) in the emergency department (ED). In the current study we sought to use a larger dataset to develop a more concise and more accurate risk scale. Methods: We analyzed data from the prior two studies and from a new cohort. For all 3 groups we conducted prospective cohort studies that enrolled patients who required treatment for AHF at 8 tertiary care hospital EDs. Patients were followed for 30 days. The primary outcome was short-term serious outcome (SSO), defined as death within 30 days, intubation or non-invasive ventilation (NIV) after admission, myocardial infarction, or relapse resulting in hospital admission within 14 days. The fully pre-specified logistic regression model with 13 predictors (where age, pCO2, and SaO2 were modeled using spline functions) was fitted to 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions, and estimated a sample size of 2,000 patients. Results: The 1,986 patients had mean age 77.3 years, male 54.1%, EMS arrival 41.2%, IV NTG 3.3%, ED NIV 5.4%, admission on initial visit 49.5%. Overall there were 236 (11.9%) SSOs including 61 deaths (3.1%), meaning that current admission practice sensitivity for SSO was only 59.7%. The final HEARTRISK6 scale is comprised of 6 variables (points) (C-statistic 0.68): Valvular heart disease (2) Antiarrhythmic medication (2) ED non-invasive ventilation (3) Creatinine 80–150 (1); ≥150 (3) Troponin ≥3x URL (2) Walk test failed (1). The probability of SSO ranged from 4.8% for a total score of 0 to 62.4% for a score of 10, showing good calibration. Choosing a HEARTRISK6 total point admission threshold of ≥3 would yield sensitivity of 70.8% (95%CI 64.5-76.5) for SSO with a slight decrease in admissions to 47.9%. Choosing a threshold of ≥2 would yield a sensitivity of 84.3% (95%CI 79.0-88.7) but require 66.6% admissions. Conclusion: Using a large prospectively collected dataset, we created a more concise and more sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of the HEARTRISK6 scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.
LO16: Predictors of appropriate hospitalization in elderly patients
Authors: Innes G. , McRae A. , Lang E. , Wang D. , Andruchow J.
Published: May 2019

Introduction: Admission decisions in older patients are often difficult. Our objectives were to identify clinical predictors of appropriate admission for older patients who attend the emergency department (ED). Methods: Administrative data were gathered on all Calgary ED patients >75 years old who were treated during 2017. We considered the following events indicative of appropriate admission: an index hospitalization lasting >72 hours, the need for ICU or CCU care, and 30-day death or readmission. Multivariable logistic regression was used to determine the association of the following potential predictors with appropriate admission: age, sex, EMS arrival, ILI symptoms, living situation (independent, homecare dependency or facility), acuity level, chief complaint, vital signs, need for IV fluid bolus ( >1Li), serum sodium, potassium, creatinine, hemoglobin, and advanced directive care level (comfort, medical, resuscitation, unspecified). Results: We studied 38866 older patients who were 55.9% female with a mean age of 84. Most (69%) lived independently, with 17% in a facility and 14% homecare dependent. Overall, 16,992 (43.7%) were admitted at their index visit and 17,340 had an outcome event, including index hospitalization >72 hours (N = 13,623, 35%), ICU care (352, 0.9%), CCU care (447, 1.2%), or 30-day death (2,241, 5.8%) or readmission (3,964 10.2%). Patients with appropriate admission events were more likely to have an advanced directive (80.7% v. 7.8%), triage hypoxia (30.5% v. 9.2%), EMS arrival (73% v. 48%), facility or homecare dependency (50% v. 15%), or to have a complaint of dyspnea (20.4% v. 8.6%), weakness (9.1% v. 3.8%) or altered mentation (8.8% v. 2.8%). Multivariable modeling showed that the strongest predictors of appropriate admission (adjusted odds ratio) were any advanced directive (OR = 30), need for IV bolus (OR = 1.67), homecare dependency (OR = 1.65), triage hypoxia (OR = 1.63), and a chief complaint of altered mentation (OR = 1.72), weakness (OR = 1.52) or dyspnea (OR = 1.25). Conclusion: The presence of an advanced care directive is strongly associated with appropriate admission in older ED patients. Other significant determinants include homecare dependency, EMS arrival, hypoxia or dyspnea, IV bolus and weakness or altered mentation. Age, sex, acuity, vital signs and laboratory findings were weak predictors.
LO25: Use of Glasgow Blatchford Score, time to endoscopy, and proton pump inhibitor use in patients presenting with upper gastrointestinal bleeding to the emergency department
Authors: Sandha S. , Stach J. , Bullard M. , Halloran B. , Blain H. , Grigat D. , Lang E. , Veldhuyzen van Zanten S.
Published: May 2019

Introduction: Upper gastrointestinal bleeding (UGIB) is a common presentation to the emergency department (ED). Early endoscopy within 24 hours has been shown to reduce re-bleeding rates and lower mortality. However, low-risk patients can often be managed through outpatient follow-up. The aim of this study was to compare the timing and appropriateness of endoscopy and proton pump inhibitor (PPI) use in a tertiary care ED setting for low- and high-risk patients determined using the Glasgow Blatchford Score (GBS). Methods: Retrospective chart review was conducted to examine the management of patients presenting with an UGIB in 2016 to the University of Alberta Hospital ED. TANDEM and Emergency Department Information System (EDIS) databases were used to identify patients using specific ICD-10 codes and the CEDIS presenting complaints of vomiting blood or blood in stool/melena. Patients with GBS 0-3 were categorized as low-risk and those with GBS > 3 were considered high-risk with appropriateness of and time to endoscopy, disposition of patient at 24 hours, and use of PPIs determined for each group. Results: A total of 400 patients were included. A total of 319/400 patients (80%) underwent esophagogastroduodenoscopy (EGD). EGD was performed within 24 hours in 37% of patients (29/78) with GBS 0 to 3 and in 77% (248/322) with GBS greater than 3. Of the remaining high-risk patients, 11% (36/322) underwent EGD after 24 hours and 12% (38/322) did not undergo EGD. The endoscopic diagnoses were peptic ulcer disease (PUD) in 41% of patients (130/319), esophagitis in 18% (56/319), and varices in 14% (45/319). PPIs (data available 375/400) were administered (mainly intravenously) to 93% (279/300) of high-risk and 79% (59/75) of low-risk patients. Data on patient disposition showed 60/322 (19%) high-risk patients were discharged from the ED within 24 hours and only 31/60 (52%) of these underwent EGD before discharge. Of 29 low-risk patients undergoing EGD within 24 hours, 9 (31%) were admitted, 17 (59%) were discharged from ED, and 3 (10%) were kept for observation in the ED greater than 24 hours. Of low-risk patients, 76% (59/78) were discharged from the ED within 24 hours. Conclusion: A majority of patients presenting with UGIB appropriately received endoscopy within 24 hours. 19% of high-risk patients were discharged from the ED. Earlier discharge for low-risk patients can be improved as only 76% of low-risk patients were discharged from the ED within 24 hours. As expected, PPI use was high in these patients.
LO31: Patients’ and caregivers’ experiences with pain management in children and teenagers with sickle cell disease requiring admission for vaso-occlusive crisis
Authors: Arbitre C. , Gaucher N. , Trottier E. D. , Bourque C. , Robitaille N. , Pastore Y.
Published: May 2019

Introduction: The quality of life of children with sickle cell disease (SCD) depends on the severity, timing and number of painful episodes (vaso-occlusive crises, VOC) and their need for medical treatment and hospitalizations. The objective of this study was to explore the experiences of pediatric patients and their families during VOC. Methods: This qualitative study used semi-structured one-on-one and focus group interviews, designed in partnership with two patients and one parent, in a single center, tertiary care pediatric university-affiliated hospital. Two groups of participants were interviewed independently: (1) adolescent patients aged 12 to 18 years old hospitalised within the last 2 years for VOC, (2) parents of pediatric patients with SCD hospitalised within the last 2 years for VOC. Data was transcribed in full and analysed using NVivo12. Descriptive thematic content analysis was performed by coding themes emerging from data. After validating codes through interjudge assessment by consensus, themes from teenagers’ and parent's discourses were systematically compared for the final analysis. Results: Between June and August 2018, 8 interviews were conducted. 10 parents and 5 adolescents participated. Teenagers’ and parents’ answers mirrored each other's. Prompt pain relief was crucial, although the side effects of pain relief medications used were an added source of suffering. Recent quality improvement initiatives such as standardised order sheets were noteworthy improvements, though personalizing care to each patient's with pharmacological and non-pharmacological methods was also important to participants. Given the unpredictability and severity of VOC, their impact on both patients’ and families’ lives were substantial, as was the long term emotional burden. Parents felt guilty given the hereditary nature of the disease, they encouraged neonatal and prenatal testing, and they sought definitive treatments for both VOC and SCD. Tensions within parent-teenager relationships were described centered on developing autonomy and protecting the child to improve adherence to treatments. Conclusion: Participants emphasized the need to provide timely adequate analgesia, through both standardised quality improvement initiatives and a personalised approach to analgesia. Understanding the impact of VOC on patients’ lives and their socio-familial context is important to tailor clinical interventions.