bluuebunny/crossref_metadata_2025 huggingface dataset:
Limbic and cortical control of phonation for speech in response to a public speech preparation stressor
Authors: Dietrich Maria , Andreatta Richard D. , Jiang Yang , Stemple Joseph C.
Published: May 2019

Knowledge on brain networks subserving vocalization in vocally healthy individuals under various task conditions is scarce but paramount to understand voice disorders. The aims of our study were to determine (1) the effect of social-evaluative stress on the central neural control of phonation underlying speech production; and (2) the neural signature, personality profile, and aerodynamic vocal function in relation to salivary cortisol responses. Thirteen vocally healthy females underwent an event-related sparse-sampling fMRI protocol consisting of voiced and whispered sentence productions with and without exposure to the social-evaluative stressor public speaking anticipation. Participants completed a personality questionnaire, rating scales of negative emotional state, and provided salivary cortisol samples. In the total sample, the task contrast of voiced productions revealed that stressor exposure resulted in a peak activation in the right caudate with concomitant deactivations in the bilateral pgACC and aMCC, and right IFG, BA 9, BA 10, insula, putamen, and thalamus. There were individual differences in stressor-induced brain activations as a function of stress reactivity with greater cortisol reactivity linked with lower laryngeal motor cortex activity and lower scores on aspects of extraversion. Our data confirm that stress alters the phonatory control for speech production through limbic-motor interactions. The findings support the Trait Theory of Voice Disorders (Roy and Bless 2000) and help provide critical insights to the study of voice disorders such as primary muscle tension dysphonia.
LO58: An education needs assessment: how can we optimize the education provided to off-service residents completing an emergency medicine rotation
Authors: Stiell A. , Karram J. , Cheung W. , Frank J.
Published: May 2019

Introduction: Over 150 Off Service Residents from 18 different programs rotate through our ED every academic year. We aim to determine the educational needs of these residents to we better design a curriculum for their ED rotation. Methods: We conducted a cross-sectional convenience sample survey of 133 Off-Service PGY-2 residents who had rotated through the ED of The Ottawa Hospital in their PGY-1 year. (from July 2016 to June 2017). The survey was emailed to residents from March to May 2018 and consisted of 19 questions. Questions were qualitative, selection from list and rank order. They focused on 3 main areas: EM rotation impact and areas for improvement, desired content, desired method of learning. Data was collected using Survey Monkey. Results: We received 70 responses (53%) from 13 different residency programs. 36 (51.4%) of respondents were from the Family Medicine program. Qualitative themes included that the ED provides great opportunity to develop the ability to workup undifferentiated patients and allows for teaching around cases. Allowing more involvement in acute care cases and having more SIM sessions could improve the rotation. The most useful topic was chest pain/cardiovascular conditions (73.3% of residents) with 16 additional ED topics listed as important for their practice. The most useful skill was suturing (51.6% of residents) with 16 other ED procedures listed as important for their practice. The preferred teaching method was SIM (48.3%) followed by small group teaching (33.3%). Conclusion: The emergency department provides an excellent learning environment for a large range of Off-Service residents early in their training. In addition to clinical shifts, a curriculum incorporating simulation and small group teaching and that covers a large scope of topics is necessary to meet the needs of these residents.
LO71: Evaluating the application of the prehospital Canadian C-Spine Rule by paramedics in sport-related injuries
Authors: Carmichael H. , Vaillancourt C. , Shrier I. , Charette M. , Hobden E. , Stiell I.
Published: May 2019

Introduction: The Canadian C-Spine rule (CCR) was validated for use by paramedics to selectively immobilize stable trauma patients. However, the CCR “Dangerous Mechanism” is highly prevalent in sports. Our objective was to compare the CCR performance in sport-related vs. non-sport-related injuries and describe sport-related mechanisms of injury. Methods: We reviewed data from the prospective paramedic CCR validation and implementation studies in 7 Canadian cities, which already included identification of sport-related injuries. A single trained reviewer further categorized mechanisms of injury using a pilot-tested standardized form, with the aid of a sport medicine physician in 15 ambiguous cases. We compared the CCR's recommendation to immobilize sport-injured versus non-sport-injured patients using chi-square and relative risk statistics with 95% confidence intervals. Results: There were 201 amateur sport-injuries among the 5,978 patients. Sport-injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs 46.8%) than non-sport-injured patients. Paramedics did not miss any c-spine injuries when using the CCR. Although cervical spine injury rates were similar between sport (2/201; 1.0%) and non-sport injured patients (47/5,777; 0.8%), the absolute number of sport-related injuries was very small. Although CCR recommended immobilization equally between the two groups (46.4% vs 42.5% p = 0.29; RR 1.17 95%CI 0.87-1.57), the reason for immobilization was more likely to be a dangerous mechanism in sport injuries (68.6% vs 54.5%, p = 0.012). Although we observed a wide range of mechanisms, the most common dangerous mechanism responsible for immobilization in sport was axial load. Conclusion: The CCR identified all significant c-spine injuries in a cohort of patients assessed and transported by paramedics. Although an equal proportion of sport and non-sports related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the CCR to evaluate all sport-related injuries in collegiate or pro athletes evaluated by sport medicine therapists and physicians, as these patients are rarely assessed by paramedics or transported to a hospital. It does support the safety and benefit of using the CCR in sport-injured patients for which paramedics are called.
LO73: The state of the evidence for emergency medical services care of adult patients with sepsis: an analysis of appraised research from the Prehospital Evidence-Based Practice (PEP) program
Authors: Greene J. , Carter A. , Goldstein J. , Jensen J. , Swain J. , Brown R. , Leroux Y. , Lane D. , Simpson M.
Published: May 2019

Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.
LO75: The impact of snowfall on patient attendance at an urban academic emergency department
Authors: Shah S. , Murray J. , Mamdani M. , Vaillancourt S.
Published: May 2019

Introduction: Accurate forecasting of emergency department (ED) patient visits can inform better resource matching. Calendar variables such as day of week and time of day are routinely used as predictors of ED volume. Further improvement in forecasting will likely come from dynamic variables. The effect of snowfall on ED volumes in colder climates remains poorly understood. We sought to determine whether accounting for snowfall improves ED patient volume forecasting. Our secondary objective was to characterize the magnitude of effect of snowfall on ED volume. Methods: This was a retrospective observational study using historical patient volume data and local snowfall records from April 1st, 2011 to March 31st, 2018 (2,542 days) at a single urban ED. We fit a series of four generalized linear models: a baseline model which included calendar variables and three different snowfall models which contained the variables in the baseline model plus an indicator variable for modelling snowfall. Each snowfall model had a different daily threshold for its indicator variable: any snowfall ( >0cm), moderate snowfall ( > = 1 cm), or high snowfall ( > = 5 cm). We modeled daily ED volume as the dependent variable using a Poisson distribution. To evaluate model fit, we examined the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) in each of the four models. In both cases, a lower number indicates better model fit. Incident rate ratios were calculated to determine the effect of snowfall. We used the delta method to calculate confidence intervals. Results: A total of 2542 days were used to develop the model. All three snowfall models demonstrated improved model fit compared to the baseline model with lower AIC and BIC values. The best fitting model included a binary variable for moderate snowfall ( > = 1cm/day). This model showed a statistically significant decrease in ED volume of 2.65% (95% CI: 1.23% -4.00%) on snowfall days, representing 5.4 (95% CI: 2.5 -8.2) patients per day at our hospital with an average daily volume of 205 patients. Conclusion: The addition of a snowfall variable results in improved forecasting model performance in ED volume forecasting with optimal threshold set at 1 cm of snow in our setting. Snowfall is associated with a modest, but statistically significant reduction in ED volume.
LO79: The impact of access block on consultation time in the emergency department
Authors: Carroll L. , Nemnom M. , Kwok E. , Thiruganasambandamoorthy V.
Published: May 2019

Introduction: Access block (AB) is the most important indicator of Emergency Department (ED) crowding, but the impact of AB on consultation time has not been described. Our objectives were to determine if ED AB affects inpatient service consultation time, and operational and patient outcomes. Methods: We conducted a health records review of all ED patients referred and admitted at a university-affiliated tertiary care hospital over 60-days. A computational algorithm determined hourly ED AB at the time of consultation request, and observational cohorts were determined based on ED AB high (>35% ED bed capacity occupied by admitted patients) or low (<35%). The outcomes included total consultation time (TCT), ED physician initial assessment (PIA) time, ED length of stay (LOS), transfer time to inpatient bed (TTB), hospital LOS, return to ED (RTED) within 30 days, and 30-day mortality. Results: We included 2,871 patients (48% male; M = 63 years, IQR 45–78), and the low AB cohort were higher acuity (N = 1,692; 50.4% CTAS 1–2) than the high AB cohort (N = 1,179; 47.1% CTAS 1–2). Median TCT was not significantly different (low = 209min, high = 212min; p = 0.09), and there was no difference in consults completed within the 3-hour institutional time target (low = 41.1%, high = 40.9%; p = 0.89). Median ED PIA time was not significantly different (low = 66min, high = 68min; p = 0.08), however, patients seen within the funding-associated provincial ED PIA time target was significantly less during high AB (high = 82.2%, low = 89.2%; p < 0.001). Median ED LOS was significantly longer during high AB (high = 12.1hr, low = 11.1hr; p = 0.009), but median hospital LOS was not different (high = 109.5hr, low = 112.4hr; p = 0.44). Median TTB was significantly longer during high AB (high = 8.0hr, low = 5.9hr; p = 0.0004). There was no difference in RTED visits (high = 12.4%, low = 10.6%; p = 0.15) or 30-day mortality (high = 8.4%, low = 9.2%; p = 0.51). Conclusion: In conclusion, consultation time is not affected by AB. However, boarding admitted patients in the ED impairs our ability to meet funding-associated performance metrics. Reducing boarding time should be an ED and hospital-wide priority, as it negatively impacts funding and delays patient care.
MP06: Impact of anticoagulation on mortality and resource utilization among critically ill patients with major bleeding in the emergency department
Authors: Mok G. , Fernando S. , Castellucci L. , Dowlatshahi D. , Rochwerg B. , McIsaac D. , Carrier M. , Wells P. , Bagshaw S. , Tanuseputro P. , Kyeremanteng K.
Published: May 2019

Introduction: Patients with major bleeding (e.g. gastrointestinal bleeding, and intracranial hemorrhage [ICH]) are commonly encountered in the Emergency Department (ED). A growing number of patients are on either oral or parenteral anticoagulation (AC), but the impact of AC on outcomes of patients with major bleeding is unknown. With regards to oral anticoagulation (OAC), we particularly sought to analyze differences between patients on Warfarin or Direct Oral Anticoagulants (DOACs). Methods: We analyzed a prospectively collected registry (2011-2016) of patients who presented to the ED with major bleeding at two academic hospitals. “Major bleeding” was defined by the International Society on Thrombosis and Haemostasis criteria. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Secondary outcomes included discharge to long-term care among survivors, total hospital length of stay (LOS) among survivors, and total hospital costs. Results: 1,477 patients with major bleeding were included. AC use was found among 215 total patients (14.6%). Among OAC patients (n = 181), 141 (77.9%) had used Warfarin, and 40 (22.1%) had used a DOAC. 484 patients (32.8%) died in-hospital. AC use was associated with higher in-hospital mortality (adjusted odds ratio [OR]: 1.50 [1.17-1.93]). Among survivors to discharge, AC use was associated with higher discharge to long-term care (adjusted OR: 1.73 [1.18-2.57]), prolonged median LOS (19 days vs. 16 days, P = 0.03), and higher mean costs ($69,273 vs. $58,156, P = 0.02). With regards to OAC, a higher proportion of ICH was seen among patients on Warfarin (39.0% vs. 32.5%), as compared to DOACs. No difference in mortality was seen between DOACs and Warfarin (adjusted OR: 0.84 [0.40-1.72]). Patients with major bleeding on Warfarin had longer median LOS (11 days vs. 6 days, P = 0.03) and higher total costs ($51,524 vs. $35,176, P < 0.01) than patients on DOACs. Conclusion: AC use was associated with higher mortality among ED patients with major bleeding. Among survivors, AC use was associated with increased LOS, costs, and discharge to long-term care. Among OAC patients, no difference in mortality was found. Warfarin was associated with prolonged LOS and costs, likely secondary to higher incidence of ICH, as compared to DOACs.
MP07: Diagnosis of elevated intracranial pressure in critically ill adults – a systematic review and meta-analysis
Authors: Fernando S. , Tran A. , Cheng W. , Rochwerg B. , Taljaard M. , Kyeremanteng K. , English S. , Sekhon M. , Griesdale D. , Dowlatshahi D. , Czosnyka M. , McCredie V. , Wijdicks E. , Almenawer S. , Inaba K. , Rajajee V. , Perry J.
Published: May 2019

Introduction: Elevated intracranial pressure (ICP) is a devastating complication of brain injury, such as traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, and other conditions. Delay to diagnosis and treatment are associated with increased morbidity and mortality. For Emergency Department (ED) physicians, invasive ICP measurement is typically not available. We sought to summarize and compare the accuracy of physical examination, imaging, and ultrasonography of the optic nerve sheath diameter (ONSD) for diagnosis of elevated ICP. Methods: We searched Medline, EMBASE and 4 other databases from inception through August 2018. We included only English studies (randomized controlled trials, cohort and case-control studies). Gold standard was ICP≥20 mmHg on invasive ICP monitoring. Two reviewers independently screened studies and extracted data. We assessed risk of bias using Quality Assessment of Diagnostic Accuracy Studies 2 criteria. Hierarchical Summary Receiver Operating Characteristic model generated summary diagnostic accuracy estimates. Results: We included 37 studies (n = 4,768, kappa = 0.96). Of exam signs, pooled sensitivity and specificity for increased ICP were: mydriasis (28.2% [95% CI: 16.0-44.8], 85.9.0% [95% CI: 74.9-92.5]), motor posturing (54.3% [95% CI: 36.6-71.0], 63.6% [95% CI: 46.5-77.8]) and Glasgow Coma Scale (GCS) ≤8 (75.8% [95% CI: 62.4-85.5], 39.9% [95% CI: 26.9-54.5]). Computed tomography findings: compression of basal cisterns had 85.9% [95% CI: 58.0-96.4] sensitivity and 61.0% [95% CI: 29.1-85.6] specificity; any midline shift had 80.9% [95% CI: 64.3-90.9] sensitivity and 42.7% [95% CI: 24.0-63.7] specificity; midline shift≥1cm had 20.7% [95% CI: 13.0-31.3] sensitivity and 89.2% {95% CI: 77.5-95.2] specificity. Finally, pooled area under the ROC curve describing accuracy for ONSD sonography for ICP was 0.94 (95% CI: 0.91-0.96). Conclusion: The absence of any one physical exam feature (e.g. mydriasis, posturing, or decreased GCS) is not sufficient to rule-out elevated ICP. Significant midline shift is highly suggestive of elevated ICP, but absence of shift does not rule it out. ONSD sonography may be useful in diagnosing elevated ICP. High suspicion of elevated ICP may necessitate treatment and transfer to a centre capable of invasive ICP monitoring.
MP21: A brief educational session is effective for teaching emergency medicine residents resuscitative transesophageal echocardiography
Authors: Chenkin J. , Jelic T. , Hockmann E.
Published: May 2019

Innovation Concet: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application that has the potential to guide the management of critically ill patients in the emergency department. The objective of this study was to determine the effectiveness of a brief training workshop for teaching a resuscitative TEE protocol to emergency medicine residents using a high-fidelity simulator. Methods: Emergency medicine residents with no prior TEE experience that were rotating through a university-affiliated emergency department were invited to participate in the study. Participants completed a questionnaire and baseline skill assessment using a high-fidelity simulator. The training session included a 20 minute lecture followed by 10 simulated repetitions of a 5-view TEE sequence with instructor feedback. Learning was evaluated by a skill assessment immediately after training and a transfer test 1-2 weeks after the training session. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. The primary outcome of this study was the percentage of successful views before and after training as determined by two blinded reviewers using an anchored scoring tool. Secondary outcomes included time to scan completion and diagnostic accuracy on the transfer test. Assessment scores were compared using a two-tailed t-test. Curriculum, Tool or Material: 22 of 25 (88%) of invited residents agreed to participate in the study. Percentage of successful views increased from 44.5% (SD 27.9) at baseline to 98.6% (SD 3.5) after training (p < 0.001), and was 86.8% (SD 12.1) on transfer testing (p < 0.001). Time to complete the scan was 330 seconds at baseline, 125 seconds after training (p < 0.001), and 184 seconds (p < 0.001) in the transfer test. Participants made the correct diagnosis in 75% (SD 25.6) of the cases in the simulated patient encounter. The descending aorta view had the highest success rate (93.2%) and the midesophageal long axis view had the lowest success rate (75.0%). Conclusion: A brief simulation-based workshop was effective for teaching emergency medicine residents a five-view resuscitative TEE protocol. Future studies are needed to determine optimal methods for long-term skill retention.
MP25: Implementation of pain order sets to decrease the time to analgesics in the emergency department: a quality improvement initiative in progress
Authors: Akilan K. , Teo V. , Hefferon D. , Verma A.
Published: May 2019

Background: Acute pain is a common presentation in the Emergency Department (ED) and inadequacy in its treatment can lengthen stay. Earlier analgesia use and discharge has been associated with positive patient experiences and improved pain management. Validated ‘fast-track pathways’ to aid physician decision making in analgesic administration is associated with decreased waiting times in renal colic diagnoses. Aim Statement: Our aim was to create an order set, for an approach to patients with acute pain, to reduce median time from point of triage to analgesia. We sought to reduce median time by 15 minutes, for ED patients with renal colic in the three months after implementation as compared to three months before. Measures & Design: We used a literature review and comparison to existing order sets at other EDs to design our draft. We focused our evaluation on patients with renal colic. We underwent multiple revisions based on stakeholder feedback and educated both physician and nursing teams about the order set. The utilization, however, was at physician discretion. We implemented the order set on March 30, 2017. After three months, an electronic retrospective chart review identified patients with a final renal colic diagnosis. For each patient, we captured triage time using electronic records and time to analgesia with the medication cart. Utilization of order sets was confirmed via manual chart audit. Evaluation/Results: A run chart showed worsening times after the intervention. Median time to analgesia in minutes, 3 months prior (n = 90) and post (n = 93) intervention, increased from 228 to 310 minutes, although the range was very large. Chart audits demonstrated a considerably low uptake of the order set with a small gradual increase from 0% to 20% over the 3-month period. Discussion/Impact: There was insufficient uptake of the Acute Pain order set preventing impact on time to analgesia. Changes in occupancy likely contributed to the worsening times. There was an increase in utilization over the 3-month period and could be due to increased awareness. This demonstrates that interventions require more than implementation to be effective. Difficulties in implementation were due to the document not being readily available. We have organized the nursing staff to attach order sets onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.
MP41: Feeling the flow: an evaluation of the GridlockED workshop experience
Authors: Hale S. , Chan T.
Published: May 2019

Introduction: GridlockED is an educational (or “serious”) game recently developed by a team at McMaster to teach medical learners about patient flow in the emergency department (ED). Beyond patient flow, we were cognizant that the game could provide additional learning opportunities for learners. The goal of this program evaluation project was to investigate workshop attendees’ experiences and identify what areas they found most educational. Methods: A GridlockED board game workshop was developed and delivered in several locations over the fall of 2018. Workshops targeted medical learners and were organized by local emergency medicine interest groups. After a standardized video-based introduction to the game concept and rules, the learners played GridlockED for approximately 90 minutes. After the play session, learners completed an anonymous survey consisting of 7-point Likert scale questions about their experience. They were also asked to identify the learning domains for which GridlockED was developed (Patient Flow, Communication and Teamwork, and ED Basics), and were asked via free-text to identify learning objectives from their experience. We received an exemption for this study from our institutional review board. Results: We had 25 respondents (24 medical students and 1 resident). Trainees rated GridlockED as both enjoyable to play and as a meaningful educational experience, with an average rating of 6.56 (SD 0.94) for enjoyability and 6.44 (0.92) for education. When asked what targeted learning domain was most helpful, 45% of students identified patient flow, 37% teamwork and communication, and only 18% ED basics. When asked to identify their top three areas of learning in open-ended responses, students actually identified resource management most frequently (48%), with improved communication skills (40%) as the second most prominent learning objective. Other interesting self-identified learning points were: a greater appreciation of the role of various providers (24%), the unpredictability of ED care (12%), and how things can go wrong (12%). Conclusion: Medical learners find GridlockED to be both enjoyable and educational. In our targeted areas of learning they found patient flow to be the most educational, but self-identified multiple other areas for learning. Students identified resource management and communication as key areas of learning, suggesting that future workshops might be designed specifically to teach these skills.
MP42: Program assessment: taking stock of the current state of Canadian undergraduate medical education in procedural skills curricula
Authors: Battaglia F. , McConnell M. , Sayed C. , Merlano M. , Ramnanan C. , Rastogi N.
Published: May 2019

Introduction: In order to better characterize procedural skills curricula in Canada, a national survey was conducted. The objectives of the survey were: (i) to characterize procedural skills education currently employed in pre-clerkship and clerkship curricula; (ii) to determine what skills physician-educators think medical students should know upon graduation; and (iii) to identify physician-educator perceptions regarding the development of pre-clerkship procedural curriculum. Methods: A web-based survey was distributed to 201 clinician-educators across Canada's 17 medical schools. Respondents were directed to an individualized survey based on their self-identified roles at their institution. Respondents were asked demographic questions, what procedural skills are being taught and in what setting at their institution, and their opinions on the value of a pre-clerkship procedural curriculum. Results: From the 17 school's surveyed, 12 schools responded, with 8 schools responding “yes” that they had a clerkship procedural curriculum. For a pre-clerkship procedural curriculum, only 4 schools responded “yes”. The 5 of the top 10 procedurals skills identified that medical students should know upon graduation, in order, are: IV Access, Airway Management/Ventilator Management, Local anesthesia/field block, Casting, Spontaneous Vaginal Delivery. On a Likert scale, clinician-educators strongly supported a pre-clerkship procedural curriculum (median = 4.00/5.00, mode = 5.00/5.00), and they believed it would decrease anxiety (median = 4.00/5.00), increase confidence (median = 4.00/5.00), and increase technical ability (median = 3.00/5.00) in incoming clerks. Conclusion: Across Canada, the state of undergraduate medical education procedural skills education is inconsistent. With the identification of the Top 10 procedural skills medical students should know upon graduation, the learning objectives of a formal curriculum can be developed. With overwhelming support from physician-educators, a formal pre-clerkship procedural curriculum is poised to redefine the landscape of procedural care for a whole new generation of physicians.
MP43: Evaluation of undergraduate point of care ultrasound instruction in a rural Canadian medical school
Authors: Kuehner Z. , Dmitriew M. , Jefkins M. , Piper B. , Byce S. , Dubois S. , Zanette C.
Published: May 2019

Introduction: Point of care ultrasound is a burgeoning tool in clinical medicine and its utility has been demonstrated in a variety of contexts. It may be especially useful in rural areas where access to other imaging equipment (such as CT) is limited. However, there exists debate about the utility of teaching ultrasound theory and technique to medical undergraduates, particularly those in their first two years of study. This study evaluated the efficacy of teaching undergraduate-tailored ultrasound training sessions to first and second-year medical students at the Northern Ontario School of Medicine (NOSM), a rural-focused medical institution. Methods: Sixty students participated in tailored ultrasound teaching sessions that involved both lecture and hands-on components. Participating students were assessed following each session, as well as at study completion, in terms of ultrasound knowledge, anatomy, pathology, orientation, and interpretation of computerized tomography (CT) scans (transferability). Participants’ performance was measured against a control group of their peers. Program evaluation was completed using Likert-type scales to determine participant comfort with ultrasound before and after the training, and areas of strength and improvement. Results: Participating students showed statistically significant improvement in ultrasound interpretation and anatomical orientation with trends toward improved anatomy and pathology knowledge, and ability to interpret computerized tomography (CT) scans compared to controls. Students participating in the course expressed improved comfort with ultrasound techniques and desire for future integration of ultrasound into their training, but noted that increasing frequency of training sessions might have improved retention and confidence. Conclusion: Results suggest that using an undergraduate-focused and system-specific ultrasound training course yields retention in ultrasound interpretation ability and objective improvement in relational anatomy knowledge. Trends toward improvement in general anatomy, pathology and CT interpretation suggest areas of future study.
MP45: Rate control management of rapid atrial fibrillation in the emergency department
Authors: Wong B. , Green M. , Stiell I.
Published: May 2019

Introduction: The Canadian Association of Emergency Physicians (CAEP) Atrial Fibrillation (AF) Guidelines prioritizes early cardioversion and discharge home in the management of rapid AF, however not all patients can be safely cardioverted in the emergency department (ED). Given limited ED-based evidence on rate control, we sought to better understand the burden of disease in AF patients not managed by rhythm control and identify opportunities for improved care. Methods: We conducted a health records review of consecutive AF patient visits at two Canadian academic hospital EDs over a 12-month period. We included all patients ≥18 years with AF on electrocardiogram, a heart rate ≥100 beats per minute (bpm), and who did not receive cardioversion. Outcomes included: (1) incidence of patients managed by rate control; (2) specific rate control management practices including choice of agent, route of administration, dosing, and timing; (3) adverse events; (4) compliance with CAEP AF Guidelines; and (5) disposition and outcomes. Results: Of 972 rapid AF patient visits, 307 were excluded and 665 were included, with mean age 77.2, female 51.6%. Of those included, 43.0% were given rate control medications, most common being metoprolol (72.0%). Admission to hospital occurred in 61.4% of visits, and 77.9% of AF cases were secondary to another medical condition. In those given rate control medications, 9.1% suffered adverse events and only 55.6% had a final ED heart rate ≤100 bpm. Inappropriate use of rate control medications was found in 44.8% of cases, specifically inappropriate choice of agent (4.5%), inappropriate route of administration (26.9%), over-dosed (2.4%), under-dosed (5.2%), and inadequate timing (5.6%). Conclusion: We demonstrated that for rapid AF patients not receiving cardioversion, most cases were secondary to a medical cause and of those receiving rate control, there were a concerning number of adverse events related to inappropriate choice of agent, route of administration, dosage, and timing. Moving forward, better awareness of the CAEP AF Guidelines by ED physicians will ensure safer use of rate control agents for rapid AF patients.
MP46: Creatine kinase in the emergency department: antiquated relic or useful adjunct in diagnosis of NSTEMI: A systematic review
Authors: Beamish D. , Maniuk T. , Mukarram M. , Thiruganasambandamoorthy V.
Published: May 2019

Introduction: The diagnosis of non-ST elevated myocardial infarction (NSTEMI) depends on a combination of history, ECG and cardiac biomarkers. Many hospitals continue to automatically order less sensitive and specific biomarkers such as Creatine Kinase (CK) alongside cardiac Troponin (cTn) as part of an extended panel of bloodwork for work-up of patients with suspected NSTEMI. Methods: We undertook a systematic review to assess the usefulness of CK measurements in addition to cTnI in NSTEMI diagnosis. Medline, EMBASE and Cochrane databases were searched from 1995 until May 31, 2018. We added additional articles after reviewing the reference list of pertinent articles and consulting experts. A total of 1123 papers were screened, of which 8 were included in the final analysis. These papers all compared CK and troponin (TnI) testing in the diagnosis of NSTEMI. Results: Of the 8 papers included in the analysis none showed CK having a greater sensitivity or specificity than the TnI assays. Furthermore, no paper originally published evidence of CK diagnosing NSTEMI when Troponin was negative. One author, when contacted, described 10% of patients diagnosed with NSTEMI as having discordant data (eg. +CK, -Troponin). However, the outcome data such as angiography and echocardiography were not available for these patients, making definitive diagnosis unclear. Conclusion: Troponin has consistently shown to have greater sensitivity and specificity than CK in the diagnosis of NSTEMI with CK adding no improvements in diagnosis. We believe CK should not be used in the emergency department work-up for NSTEMI diagnosis.
MP56: A National survey of burnout and mentorship programs amongst Royal College Emergency Medicine residents
Authors: Liu R. , van Aarsen K. , Sedran R. , Lim R.
Published: May 2019

Introduction: In recent years, there has been growing interest in the field of physician wellness and burnout. Past research has shown that the prevalence of burnout is non-uniform between specialties and is most prevalent amongst emergency medicine physicians. Additionally, burnout can be observed amongst individuals early in their medical careers, including medical students and residents. To date, there is no national perspective of burnout amongst Canadian Royal College of Emergency Medicine (EM) residents. Our study looks to provide a national survey of burnout in this population as well as characterize mentorship programs at training sites. Methods: An anonymous electronic survey was e-mailed to Canadian EM residents via local program directors. Characteristics of mentor-mentee relationships and quality of residents’ mentorship experiences were assessed on a 6-point Likert scale. The Maslach Burnout Inventory – Human Services Survey (MBI-HSS) for medical personnel was used to assess burnout on three dimensions (emotional exhaustion, depersonalization and personal accomplishment). Burnout was dichotomized as present or absent if the MBI criteria are met (emotional exhaustion score > 26 or depersonalization score > 9 or personal accomplishment <34). Results: To date, 52 responses have been collected. Respondents are primarily male (63%) and in their PGY year 1-3 (71%). Responses were collected from 6/14 (43%) of eligible programs. 84% of residents currently had an emergency medicine mentor. Of these, 8% were dissatisfied with their residency's mentorship program and 55% were satisfied/very satisfied. 72% of residents met the threshold for burnout in at least one dimension of the MBI (3 dimensions = 17%; 2 dimensions = 17%; 1 dimension = 38%) and 13% cited considering suicide during their training. Conclusion: Results thus far suggest significant burnout amongst Royal College of Emergency Medicine residents. Alarmingly, 13% of responders cited having contemplated suicide during their training. These results point to an important opportunity to better support EM residents during their training to improve wellness and reduce burnout. Our findings suggest a high prevalence of residents with established mentors and future analyses will examine the correlation between mentorship characteristics and resident burnout levels.
P001: Continuing professional development and faculty development: launching continuous practice enhancement for academic emergency physicians
Authors: Addleman S. , Yeung M. , Yiu S. , Mastoras G. , Tse S. , Frank J.
Published: May 2019

Innovation Concept: Emergency medicine physicians must maintain a broad knowledge base and procedural skillset while fulfilling their academic roles as teachers, researchers and administrators. Most academic departments do not have a regular, affordable, formal continuing professional development (CPD) and faculty development (FD) curriculum for their staff. We set out to design and implement a novel continuous practice enhancement program to address this issue. Methods: Strategic planning by the Ottawa academic Department of EM identified CPD and FD as priorities. A program was created to support high quality, monthly CPD/FD courses provided by physicians. We had 5 goals: (1) enhance clinical and academic skills, (2) disseminate group best practices, (3) sustain skills in high impact/low frequency scenarios, (4) support physician academic careers, and (5) acquire new procedural skills. A CPD/FD Committee composed of local meded experts and experienced clinical teachers was tasked with overseeing the creation and evaluation of these sessions. Curriculum, Tool or Material: The longitudinal curriculum was informed by perceived needs (group survey), ascribed needs (M&M rounds, physician metrics and departmental leadership priorities) and participant feedback. The committee identified local experts to present on their areas of expertise in order to promote group best practice. Topics to-date have included clinical skills updates, teaching and coaching strategies and academic career planning. A comprehensive monthly simulation-based curriculum was rolled out simultaneously to give participants the opportunity to develop crisis resource management and critical care skills. Except for sessions requiring advanced equipment or cadavers, sessions are financed by academic funds and free for participants. Conclusion: Faculty academic learning and engagement is an important goal and participation in this curriculum is reviewed at each physician's annual reappointment. To-date, 18 physicians (21% of our group) have presented topics and 92% of physicians have participated in at least one session with 63% having attended three or more. Evaluations have been overwhelmingly positive, and a recent survey identified the CPD/FD program as a significant contributor to our physicians’ wellness. We introduced an innovative, structured CPD/FD program in response to perceived and ascribed needs of our physicians and departmental leadership. Our successful CPD/FD curriculum represents a model for other departments who are considering similar initiatives.
P005: An opportunity to reduce morbidity in delayed postpartum hemorrhage: Multicentre analysis of tranexamic utilization in the emergency department
Authors: Amat C. , Wang D. , Lang E.
Published: May 2019

Introduction: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to be efficacious and safe in reducing mortality and morbidity if given within 3 hours of bleeding onset. Delayed PPH of more than 24 hours after delivery is a rare but high-risk ED presentation that requires timely management with TXA. This study aims to evaluate the patterns of TXA administration to treat delayed PPH in the ED using a retrospective review of medical reviews from 4 centres across a major urban Canadian city. Methods: We conducted a retrospective medical record review of patients presenting with PPH to 4 large urban EDs from 2013 to 2017; from 1.5 million ED visits, using a search for ICD-10 diagnostic codes of interest. Of these, the study cohort included only patients that were admitted to the hospital. Univariate analyses using Chi-squared tests and t-tests for non-continuous and continuous variables, respectively, were used to determine patient demographics and clinical characteristics significantly associated with TXA administration. Results: A total of 238 patients were included in the study cohort. Of these patients, 72.7% presented to the ED with mild hypovolemic shock, defined by a shock index score greater than 0.6. A total of 12.6% (95% CI 0.09-0.17) of patients were given TXA for PPH management in the ED. 67% (95% CI 0.47-0.82) of patients received the TXA within 3 hours of triage, whereas 33% (95% CI 0.18-0.53) received it after 3 hours, with the total mean time at 3.43 hours. 4.2% of patients required a blood transfusion and 2.9% required surgery. Univariate analyses indicated that greater maternal age (p = 0.028), lower hemoglobin levels (p = 0.014), higher shock index scores (p = 0.001), greater heart rate (p = < 0.001)), and use of oxytocin (p = <0.001) or blood products (p = < 0.001) in the ED were all significantly associated with TXA administration. Conclusion: The results from this study demonstrate that only 13% of delayed PPH patients presenting to the ED received TXA, and among those treated, 66% received TXA within 3 hours of presentation. The use of TXA was correlated with variables associated with an increased risk of morbidity. Given the rarity of delayed PPH presentation to the ED, the development of a treatment algorithm is recommended to ensure higher levels of timely TXA administration.
P020: Impact of dexamethasone dose on return visits at a tertiary pediatric emergency department
Authors: Cherry J. , Fitzpatrick E. , Slaunwhite E. , Hurley K.
Published: May 2019

Introduction: Croup is a common viral upper airway infection in children aged 6 months to 6 years. Although a single dose of dexamethasone decreases return visits, the prescribed dose varies from 0.15mg/kg to 0.6mg/kg. Our objective was to examine the effect of varied dexamethasone dosing on unplanned return ED visits for croup. Methods: This was a retrospective chart review of IWK ED patient treatment records from September 1, 2014 – August 31, 2016 of children aged 6 months to 6 years with an ICD-10 discharge diagnosis code of croup. Data were abstracted by trained research assistants using a structured data collection form in REDCap. A sample of 5% of charts had double data abstraction to test for agreement. Our primary outcome was return visits to the ED within 7 days. Secondary outcomes were ED length of stay (LOS), admission to hospital and admission to the pediatric intensive care unit (PICU). Data were analyzed using descriptive statistics and chi-square for between group comparisons. Results: The dataset included 1595 patient visits for croup. Data analysis is in progress. Triage acuity as per CTAS included: resuscitation n = 5; emergent n = 351; urgent n = 558; less urgent n = 605; and, non-urgent n = 2. Most patients had no co-morbid conditions (n = 1548). Dexamethasone dosing varied: 0.15 mg/kg n = 64; 0.3 mg/kg n = 838; and, 0.6 mg/kg n = 493. ED LOS was under 1 hour in 483 patients, 1-3 hours in 805, 3-6 hours in 225 and 6-12 hours in 9 patients. Few patients were admitted to hospital (n = 22) and no patients were admitted to PICU. Within 7 days of the index visit, 78 patients had an unplanned return visit to the ED for croup. Conclusion: The data analysis is in progress. This study will inform our future research on a practice change in our ED to comply with the dose of dexamethasone recommended by the Canadian Pediatric Society for the treatment of croup in 2017.