bluuebunny/crossref_metadata_2025 huggingface dataset:
P017: Chart audit of patients with no fixed address presenting to the emergency department to identify areas to improve care
Authors: Todorovich S. , Giffin D. , Columbus M.
Published: May 2020

Background: Homelessness is a growing Canada-wide concern. Those with no fixed address have increased rates of emergency department (ED) utilization and increased healthcare spending compared to the general population, with higher rates of acute and chronic illnesses, as well as all-cause mortality. EDs are uniquely situated to act as an access point to the network of available community services, however referral rates from the ED is uncertain. To date, there has been no data collected on London, Ontario's homeless population, their health burden, and their utilization patterns of the ED. Aim Statement: The primary objective of this study is to describe ED visits for adult patients with no fixed address in London, Ontario to assess for potential areas to improve care. Measures & Design: This is a retrospective chart review, of patients with no fixed address visiting London, Ontario Emergency Departments in 2018. ED visits were identified and pulled using either a diagnosis of “homeless”, a lack of postal code, or a postal code for a known shelter. Cases included based on postal code were manually reviewed to determine whether the patient had a resident address with the same postal code. Evaluation/Results: From this search, 4,294 visits were identified for 1237 unique patients. The median visits per person was 1 (IQR 1-2), with 388 patients having 3 or more visits, and the max being 138 visits. The median age was 38 (IQR 28-52), with 73% male. Ground ambulance was used for 46% of visits. 28% of visits were CTAS 1&2 and 5% were CTAS 5. Police facilitated visits in 401 cases. Top 3 discharge diagnosis categories were mental health (19%), infection (18%), drug misuse (17%). Discussion/Impact: Several errors were identified with our search strategy suggesting the current system of capturing homelessness in the EPR is not accurate, leading to an underestimation of the problem and limiting our ability to describe this population. The Ministry of Health mandates homelessness be applied as a tertiary discharge diagnosis during coding of the patient visit if possible. However, use of this code is inconsistent leading to large-scale omission of visits and an underrepresentation of pediatric cases. Systemic steps should be taken to improve identification of these patients moving forward.
P023: Development of a Canadian Global Health Emergency Medicine (GHEM) Certificate Program based on established best practices
Authors: Stefan R. , Maskalyk J. , Ritchie L. Puchalski , Salmon M. , Landes M.
Published: May 2020

Innovation Concept: Global health fieldwork is valuable for Canadian residents, but is often trainee-organized, short-term, unsupervised, and lacking in preparation and debriefing. In contrast, we have developed a Certificate Program which will be offered to University of Toronto (UofT) emergency medicine (EM) trainees in their final year of residency. This 6-month Program will complement the Transition to Practice stage for residents interested in becoming leaders in GHEM. Methods: We completed a multi-phase needs assessment to inform the structure and content of a GHEM Certificate Program. Phase 1 consisted of 9 interviews with Program Directors (PDs), Assistant PDs, and past fellows from existing GH fellowships in Canada and USA to understand program structure, curriculum, fieldwork and funding. In Phase 2 we interviewed 4 PDs and fellows from UofT fellowship programs to understand local administrative structures. In Phase 3 we collected feedback from 5 UofT residents and 7 faculty with experience in global health to assess interest in a local GHEM Program. All interview data was reviewed and best practices and lessons learned from key stakeholders were summarized into a proposed outline for a 6-month GHEM Certificate Program. Curriculum, Tool, or Material: The Program will comprise of 1) 3 months of preparatory work in Toronto followed by 2) 3 months of fieldwork in Addis Ababa, Ethiopia. Fieldwork will coincide with activities under the Toronto-Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM). The GHEM trainee's work will support TAAAC-EM activities. Preparatory months will include training in specific competencies (POCUS, teaching, tropical medicine, QI) and meetings between the trainee and a UofT mentor to design an academic project. During fieldwork, the trainee will do EM teaching (75% of time) and complete their academic project (25% of time). A UofT supervisor will accompany, orient and supervise the trainee for their first 2 weeks in Addis. Throughout fieldwork, the trainee will be required to debrief with their UofT mentor weekly for academic and clinical mentoring. One AAU faculty member will be identified as a local supervisor and will participate in all evaluations of the trainee during fieldwork. Conclusion: This Program will launch with a call for applications in July 2021, expecting the first trainee to complete the Program in 2022-23. We anticipate that this Program will increase the number of Canadian EM trainees committed to global health projects and partnerships throughout their career.
P029: Requesting prescriptions in the emergency department: the patient, the request and the response
Authors: Shepherd L. , Mucciaccio M. , VanAarsen K.
Published: May 2020

Introduction: Patients presenting to the Emergency Department (ED) for the sole purpose of requesting prescriptions are problematic. Problematic for the patient, who may have a long wait to be seen and may leave dissatisfied. Problematic for the ED physician, who is in the business of episodic not comprehensive care and is diligently trying to avoid the misappropriation of medications. The primary objective of this study was to determine the characteristics of patients who present to the ED or Urgent Care Centre (UCC) requesting a prescription, the nature of these requests and the resulting action by the attending physician. The secondary objective was to determine the proportion of medication requests and responses that have potential street value. With this knowledge we may be better positioned to serve these patients and support physician decision-making. Methods: This was a single-centre, retrospective electronic chart review looking at all adult patients with a presenting complaint of medication request who attended a two-site tertiary ED or an Urgent Care Centre (UCC) in London, Ontario between April 1, 2014 and June 30, 2017. Data was tested for normality and analyzed using descriptive statistics. Results: A total of 1923 cases met the inclusion criteria. Cases were removed (n = 421) if it was unclear which prescription was requested or if a non-medication prescription or injection was requested. The patient median (IQR) age was 44 (32-54) with 58% being male and 55% having a family doctor. There were a total of 2261 prescriptions requested by 1502 patients. The top 3 most commonly requested classes of medications were opioids 433/1502 (28.8%), antidepressants/antipsychotics 371/1502 (24.7%) and benzodiazepines 252/1502 (16.8%). The median (IQR) wait time was 73 minutes (35-128). 298/1502 (19.8%) of patients received their requested prescription (opioids 12.7%; antidepressant/antipsychotic 55.3% and benzodiazepines 16.3%). 740/1502 (49.3%) of patients requested a medication that had street value. Of those, 118/740 (15.9%) received the requested medication. Conclusion: There is no “one size fits all” solution for the patient who presents to the ED requesting a prescription. The large number of requests for psychiatric medications suggests a service gap for mental health patients in the community. This data supports the need for comprehensive electronic medication records to guide physicians’ decisions.
P030: Assessment of lab results on emergency department patients that leave without seeing a physician
Authors: Shelton D. , Thomas-Boaz W.
Published: May 2020

Background: Most emergency departments (ED) utilize medical directives to initiate lab investigations for patients prior to physician assessment. This practice facilitates expedited patient care in the ED, resulting in safer and efficient care. However, some patients choose to leave the ED prior to seeing a physician due to prolonged waiting. Previously, at our hospital there was no defined process for identifying and following up on abnormal test results on patients that leave without being seen (LWBS), resulting in lab results often not being reviewed by a nurse or physician. Aim Statement: By April 2020, we aim to have 90% of ED LWBS patients with abnormal results identified and followed up. Measures & Design: A series of consultations and information gathering occurred that included an environmental scan of other EDs and discussions with emergency nurses, emergency physicians, Risk Management, Legal Department, College of Nurses of Ontario and Canadian Medical Protective Association. A process map was developed collaboratively to standardize the process to identify and follow up on abnormal investigations of LWBS patients and a new hospital policy was developed to officially outline this process. The following are the family of measures: Outcome measure – % LWBS patients with abnormal tests that had follow-up documented in chart Process measure – Number LWBS patients with investigations initiated by medical directive, Number LWBS patients, % LWBS patients Balancing measure – Satisfaction of nurses with new process for LWBS patients Evaluation/Results: At baseline, 29% of LWBS patients with abnormal lab results had follow up documented in the chart. After implementation of the new standardized process and policy, the follow up rate of LWBS patients with abnormal results in August, September and October 2019 was 47%, 28% and 29% respectively. Discussion/Impact: These results indicate that standardization and new policy implementation is insufficient to change practice, even one that aims to provide safer patient care. Nevertheless, these interventions are important first steps to improving the safety for ED LWBS patients. We plan to implement an audit and feedback approach to encourage nursing staff to routinely check lab results on LWBS patients.
P031: Multidisciplinary healthcare and first aid provider training for in-flight medical emergencies: a crowdsourcing session followed by an airplane simulation
Authors: Seto A. , Kariath J.
Published: May 2020

Innovation Concept: Is there a healthcare provider on board? Healthcare providers may be less confident for in-flight medical emergencies (IFME), as these situations are not part of usual curriculum or practice contexts (e.g. hospitals). For example, the literature reveals that medical students and physicians lack IFME basic knowledge and preparedness. The goal is to pilot a training session for healthcare providers to improve their confidence in navigating IFME. Methods: This training innovation involved: i) a session to crowdsource insights from multidisciplinary healthcare and first aid providers, followed by reviewing considerations of a CMAJ 2018 article on airplane emergencies, and ii) 2 airplane simulations (syncope and cardiac arrest). During crowdsourcing, 7 IFME learning objectives were explored: i) challenges, ii) solutions, iii) equipment, iv) taking vitals, v) general approach, vi) cardiac arrest approach, and vii) human resources / role-delegation. Knowledge and approaches extracted were then applied in simulations. Participants provided scores out of 7.00 for: i) satisfaction of crowdsourcing session and simulation and ii) self-rated confidence on learning objectives at baseline, post-crowdsourcing session, and post-simulation. Results were analyzed with repeated measures ANOVA with post-hoc Tukey. Curriculum, Tool, or Material: The workshop curriculum was a crowdsourcing session and simulation to mentally rehearse and practice clinical skills in airplane settings to improve IFME preparedness. Conclusion: Participants rated the crowdsourcing activity (6.70/7.00, n = 11) and simulation (6.50/7.00, n = 11) positively. Confidence in the 7 topics improved from baseline (2.49/7.00) to post-crowdsourcing (5.23/7.00) to post-simulation (5.94/7.00). Significant differences (p < 0.01) between baseline and post-crowdsourcing, and between baseline and post-simulation were observed. There was no significant difference between post-crowdsourcing and post-simulation. One simulation limitation was not all could be rescuers; therefore, debriefing is important to meet learning objectives. Second, the simulation was not within an airplane; housing simulations inside an airplane with flight attendants is a potential next step. Overall, self-confidence in topics of IFME may improve after just one crowdsourcing session, facilitated through group discussions and mental rehearsal. Added simulations may maintain self-confidence on these topics, by promoting memory retention through active learning and repetition.
P035: Improving emergency department outcomes for Alberta seniors
Authors: Sandhar G. , Kruhlak M. , Krebs L. , Gaudet L. , Couperthwaite S. , Rowe B.
Published: May 2020

Introduction: In 2010, Alberta Health Services (AHS) introduced Transition Coordinators (TC), a unique nursing role focused on assessment of elderly patients to support safe discharge home. The objective of this study is to describe patient characteristics to predict safe discharge for seniors (≥65 years of age) and identify barriers that can be used to improve ED outcomes for these patients. Methods: Two trained research assistants conducted a chart review of the TC referral form and the ED Information System (EDIS) for patients seen by TCs between April and June 2017. Information on patient characteristics, existing home care and community services, the index ED visit and subsequent revisits were extracted. Data were entered into a purpose-built database in REDCap. A descriptive analysis was conducted; results are reported as mean ± standard deviation (SD), median (interquartile range [IQR]), or proportions, as appropriate. Results: A total of 1411 patients with TC referral forms were included (779 [55%] female). The majority of these patients were ≥65 (1350 [96%]) with a mean age of 82 ± 9.6. The majority of patients were triaged as a CTAS of 3 (835 [59%]) with the most common reasons for presentation including: shortness of breath (128 [9%]), abdominal pain (94 [6.7%]), and general weakness (81 [5.7%]). Nearly one third of patients (391 [30%]) were already receiving home care services; (96 [7%]) received a new home care referral as a result of their ED visit. Of all the patients, 1111 (79%) had comorbidities (median: 3 [IQR: 1 to 5]). Overall, 38% (n = 536) patients had visited the ED in the 12 months prior to the index with a median of 2 [IQR: 1 to 4) visits. On average, patient's length of stay for their index visits was 12 ± 0.35 hours. Admissions occurred for 599 [42%] patients with delays being common; the mean time between the decision to admit and the patient leaving the ED was 6 hrs ± 0.23. Conclusion: Seniors in the ED are complex patients who experience long lengths of stay and frequent delays in decision-making. Upon discharge, few patients receive referrals to community supports, potentially increasing the likelihood of revisits and readmissions. Future studies should assess whether the presence of TCs is associated with better outcomes in the community.
P040: Retrospective assessment of discrepancies in preliminary radiological reports in the emergency department
Authors: Saha N. , Chakraborty S.
Published: May 2020

Background: Preliminary reports and subsequent immediate management decisions of radiological scans are often performed by emergency physicians and on-call radiology residents. Many academic hospitals have resident-only coverage for after-hour shifts. Generally, these preliminary reports are eventually reviewed by a staff radiologist, during which discrepancies may be identified. Depending on the severity of the discrepancy and the time taken to notify the treating physician, there is potential for significant impact on the patient's care. Aim Statement: In an attempt to identify and minimize errors in radiological readings, and to improve the communication of discrepancies, our project aims to retrospectively audit all radiological discrepancies that have occurred at The Ottawa Hospital's emergency departments from April 2018 to May 2019. Measures & Designs: A systematic review of all cases with noted radiological discrepancies was obtained from the Picture Archive and Communication System software and EPIC platform. Analysis of these cases will allow us to define when errors occur, what is the type and severity of the error, how long it took to relay the discrepancy to a treating physician, and what was the subsequent management impact. Evaluation/Results: We discovered 712 cases with radiological reading discrepancies, 168 major, 527 minor, and 17 incidentals. Interestingly, a significant portion of major (severely affecting care/life-threatning) discrepancies were reported from radiology residents, especially on CT images, although emergency physicians had the most discrepancies (mostly minor). Radiology residents were seen to have more discrepant reports during after-hour services while emergency physicians did not show any specific pattern of discrepant reporting. The average time to report a major discrepancy to a treating physician is 8.8 hours, where the maximum time taken was 104 hours and the minimum was 0.2 hours. 56% of reports with major discrepancies made no mention of who was notified. Discussion/Impact: By identifying weak points in radiological reporting, our results will allow us to provide suggestions at an administration and teaching level to minimize discrepancies. It is critical to create a workflow where mistakes are mitigated, and communication is efficient and standardized to prevent patient harm from delayed or incorrect diagnosis.
P041: Point-of-care ultrasound utilization and monetary outcomes (POCUMON) study
Authors: Rusiecki D. , Douglas S. , Bell C.
Published: May 2020

Introduction: Point-of-care ultrasound (POCUS) is an integral tool in the modern emergency physician's toolkit. Evidence suggests many imaging and lab investigations are ordered without true medical indications; it is unknown how POCUS utilization impacts health care costs at a patient level. The purpose of this study was to assess whether POCUS use in the emergency department (ED) was associated with cost savings via decreased laboratory and radiographic testing. Methods: POCUMON is a single-center, prospective pilot study. The participants were a convenience sample of ED staff physicians and PGY-5 Emergency Medicine (EM) residents working in the ED from July-October 2019. Physicians who used POCUS as part of their assessment had the cost of their patient investigation plans compared with those proposed by a control group of ED physicians simultaneously on-shift. The control group was blinded to the POCUS findings but had access to the patient and medical record. The lab investigations and imaging studies ordered by both groups were recorded with respective costs. Data were analyzed using a paired T-test, with sub-group analyses. Ethics approval was obtained from the Queen's University HSREB (No.6026732). Results: 50 patient assessments using POCUS were captured in the study period. 76% of patient assessments were performed by EM staff physicians; 94% of control assessments were provided by EM staff physicians. Patient chief complaints included abdominal pain (7), chest pain/dyspnea (10), flank pain (3), pregnancy concerns (4), trauma (7), extremity complaints (4), back pain (3), and other (12). The POCUS group had a trend for lower number of laboratory tests (4.7 ± 0.44 vs 5.22 ± 0.39; p = 0.28) and imaging studies (0.94 ± 0.14 vs 1.1 ± 0.11; p = 0.33). Overall health care costs were similar in both groups, with a trend to cost savings in the POCUS group ($142.00 ± 15.44 vs $174.60 ± 17.00; p = 0.12). Subgrouping identified significant cost savings in the POCUS group for patients with a chief complaint of flank pain ($43.64 vs $248.82, p = 0.01). Conclusion: POCUS use was not associated with significant health care cost savings. ED POCUS usage did see a trend towards decreased laboratory and imaging investigations. Patients presenting with flank pain had significantly lower expenditures associated with their visit when POCUS was incorporated into their assessment. Large scale prospective studies are needed to investigate if POCUS is associated with cost-savings in ED patients.
P044: Outcomes of direct observation of trauma resuscitation
Authors: Quirion A. , Nikouline A. , Nolan B. , Jung J.
Published: May 2020

Introduction: Trauma resuscitations are sporadic high acuity situations that can be difficult to assess for areas of quality improvement. We aim to analyse the type of observation that occurs during trauma resuscitations and outcomes that develop as a result. Methods: Medline was searched from 1946 to May 2019 for studies involving direct observation of trauma resuscitation. English studies of both adult and pediatric populations from 2000 onwards were included for study. They were compared for type of observation (in-person vs video) as well as primary outcomes of their observation and any quality improvement as a result. Results: A total of 413 publications were identified with 10 meeting eligibility for inclusion. All 10 studies underwent video review with no in-person review being performed. The most common primary outcome was analysis of a critical procedure (6 studies), with tracheal intubation being studied in 4 studies and thoracotomy and vascular access each being studied once. The remaining studies measured communication styles and team effectiveness. Overall 5 of the 10 studies resulted in new policies being put in place for trauma resuscitations, including; use of interosseous lines as first lines in trauma patients in extremis, tracheal intubation check list, and continuing with medical student participation in cardiopulmonary resuscitation. Conclusion: This study highlights some of the common focuses of trauma resuscitation observation; critical procedures, team dynamics and communication. A majority of studies focused on critical procedures during resuscitations and quality improvement in the form of checklists to improve them. Remaining studies focused on equally important aspects of team functioning and communication which can be more difficult to objectively measure and derive quality improvement measures for. These studies led an emphasis on use of a horizontal assessment style and closed loop communication in all their trauma resuscitation.
P045: Doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care
Authors: Purdy E. , Mclean D. , Alexander C. , Scott M. , Donahue A. , Campbell D. , Wullschleger M. , Berkowitz G. , Henry D. , Brazil V.
Published: May 2020

Background: Trauma care represents a complex patient journey, requiring multi-disciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, cooperation and coordination across diverse groups. Aim Statement: We aimed to define and set the agenda for improvement of the relational aspects of trauma care at a large tertiary care hospital. Measures & Design: We conducted a mixed-methods collaborative ethnography using the Relational Coordination survey – an established tool to analyze the relational dimensions of multidisciplinary teamwork – participant observation, interviews, and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance. Evaluation/Results: We engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation program in contributing positively to team culture and relational ties. A range of 16 interventions – focusing on structural, process and relational dimensions – were co-created with participants and are now being implemented and evaluated by various trauma care providers. Discussion/Impact: Through engagement of clinicians spanning organizational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage health care leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.
P046: Physicians experience with the Epic electronic health record system: findings from an academic emergency department implementation
Authors: Price C. , Calder-Sprackman S. , Cheung W. , Clapham G. , Kwok E.
Published: May 2020

Introduction: In June 2019, The Ottawa Hospital launched the Epic EHR system, which transitioned all departments from a primarily paper-based system to an exclusively electronic system using a one-day “big bang” approach. All Emergency Physicians (EP) received online module training, personalization sessions, and at-the-elbow support during the transition. We sought to evaluate EP satisfaction with the implementation process and the system's impact on clinical practice in a tertiary care academic emergency medicine setting. Methods: Email surveys were distributed during the pre-implementation and go-live phases. Questions were developed by the research team and piloted for face validity and clarity. Surveys were sent to staff EPs, residents and fellows. Likert scales were used to evaluate agreement with statements and the modified Maslach Burnout Inventory was used to assess burnout. Pre-post groups were compared using chi-squared tests to assess for significant differences. Future surveys will be distributed in 2020 for continued implementation evaluation. Results: Response rates were 49% (78/160) in the pre and 48% (76/160) in the post period. The majority of respondents were staff (66% pre; 75% post) working 8-15 shifts/month. Prior to launch, 52% of EPs felt the pre-training modules provided sufficient preparation, however only 32% felt this way after go-live (p = 0.02). Providers did not feel there were enough personalization (21% pre vs. 24% post, p = 0.66) or hands-on sessions offered (51% pre vs. 39% post, p = 0.15) and this opinion did not change after go-live. Before Epic, EPs were most concerned with productivity/efficiency, documentation time, and lack of support/training. Although documentation was reported to be easier after go-live by 69% of EPs, reviewing documents, using standardized workups/protocols, patient monitoring/follow-up, efficiency and billing were reported by >50% of EPs to be more difficult. Overall, there was a 22% increase in feeling confident to use Epic (28% pre vs. 50% post, p < 0.01); however, only 38% of providers were satisfied with the system. Notably, 82% of EPs reported experiencing moderate or high burnout in the post implementation period. Conclusion: Despite receiving standard EHR training and support, the majority of clinicians did not feel adequately trained or confident using Epic and reported moderate to high burnout. These findings will inform optimization efforts and they represent key considerations for other EDs planning future implementations.
P048: Brief online educational intervention improves emergency physicians’ and general surgeon's ability to interpret focused gallbladder ultrasound
Authors: Peng S. , Woo M. , Glen P. , Ritcey B. , Cheung W. , Kwok E. , Sheikh A.
Published: May 2020

Introduction: Biliary colic is a frequent cause for emergency department visits. Ultrasound is the initial test of choice for gallstone disease. We evaluated the effectiveness of a brief online educational module aimed to improve Emergency Physicians’ (EP) and General Surgeons’ (GS) accuracy in interpreting gallbladder ultrasound. Methods: EPs and GSs (resident/fellow and attending) from a single academic tertiary care hospital were invited to participate in a pre- and post- assessment of the interpretation of gallbladder ultrasound. Demographic information was obtained in a standardized survey. All questions developed for the pre- and post- assessment were reviewed for content and clarity by 3 EP and GS experts. Participants were asked 22 multiple-choice questions and then directed to a 7-minute video-tutorial on gallbladder ultrasound interpretation. After a 3-week period, participants then completed a post-intervention assessment. Following pre- and post- assessment, participants were surveyed on their confidence in gallbladder ultrasound interpretation. Data was analyzed using descriptive statistics and paired t-test. Results: The overall response rate of the pre-intervention was 50.9% (116/228) and 40.8% (93/228) for the post-intervention. In pre-intervention assessment, 27.7% of participants reported they were “not at all confident” in interpreting gallbladder ultrasound. This contrasted with post-intervention confidence level, where only minority (7.8%) reported “not at all confident”. There was a significant increase from the pre- to post- intervention (75.7% to 85.4%; p < 0.01) in correct interpretations. The greatest improvement was seen in those with previous experience interpreting gallbladder ultrasound (from 79.6% to 91.1%; p < 0.01). EPs scored significantly higher than GSs in the pre-intervention (EPs 78.2% compared to GSs 71.0%; p < 0.01). This trend was also observed in post-intervention, although the difference was no longer significant (EPs 88.9% compared to GSs 82.8%; p = 0.05). There was no significant difference in performance between residents/fellows compared to attendings. Conclusion: This brief, online intervention improved the accuracy of EPs’ and GSs’ interpretation of gallbladder ultrasound. This is an easily accessible tutorial that can be used as part of a comprehensive ultrasound educational program. Further studies are required to determine if EPs’ and GSs’ interpretations of gallbladder ultrasound impacts patient-oriented outcomes.
P052: Who are the super-users of the emergency department?
Authors: North R. , Savage D. , VanderBurgh D. , McKay G. , McMillan C. , Jefferies A. , Piper B. , Stonebridge R.
Published: May 2020

Introduction: All emergency departments (EDs) across Canada can identify a group of high frequency users, which are typically defined in the literature as eight to ten visits per year. Although frequent users of the ED are well-studied in the literature, there is little published in terms of identifying the “super-user” group who present to the ED much more often than 10 visits per year. Faced with multiple co-morbidities and a high mortality rate, the ED is often the most appropriate environment to manage this population. In order to inform future initiatives to improve health outcomes, we aimed to identify the specific characteristics of this super-user group. Methods: A retrospective chart review was conducted using the electronic medical record from the Thunder Bay Regional Health Sciences Centre to identify patients who had at least 25 visits in the year 2017. A total of 75 patients presented to the ED greater than 25 times in 2017. The following data was then collected on each individual patient: demographic characteristics including age, gender, address, access to a primary care provider. In addition, we collected date, time, diagnoses at each visit, admission rate and surgical interventions. Results: Our preliminary results reveal this population presents to the ED on average 32 times per year. The population is 53% male. Most have a private address and half have a primary care provider for all 2017 with one quarter having a primary care provider for part of the year. The percentage of visits for infections was 30%, mental health and addictions presentations comprised 28% of the visits, with gastrointestinal and cardiac visits comprising a total 22% of the visits. Approximately 7% of visits required admission to hospital, and the average length of stay was 5 days. Conclusion: Super-users of the ED are a unique population that are typically well connected with primary care and have a very low admission and surgical rate. The most common reasons for visit are infections and mental health and addictions. The next steps include collecting mortality data. This data should be used to inform ED and community initiatives aimed at improved health outcomes for this population.
P055: Canadian emergency physician attitudes toward endotracheal intubation for aspiration prophylaxis
Authors: Munn M. , Laraya J. , Boivin-Arcouette G. , van der Linde E. , Lund A. , Turris S.
Published: May 2020

Introduction: Emergency patients with decreased level of consciousness often undergo intubation purely for airway protection from aspiration. However, the true risk of aspiration is unclear and intubation poses risks. Anecdotally, experienced emergency physicians often defer intubation in these patients while others intubate to decrease the perceived clinical and medico-legal consequences. No literature exists on the intubation practices of emergency physicians in these cases. Methods: An online questionnaire was circulated to members of the Canadian Association of Emergency Physicians. Participants were asked questions regarding two common clinical cases with decreased level of consciousness : (1) acute, uncomplicated alcohol intoxication and (2) acute, uncomplicated seizure. For each case, providers’ perceptions of aspiration risk, the standard of care, and the need for intubation were assessed. Results: 128 of the 1546 Canadian physicians contacted (8.3%) provided responses. Respondents had a median of 15 years of experience, 88% had CCFP-EM or FRCPC certification, and most worked in urban centers. When intubating, 98% agreed they were competent and 90% agreed they were well supported. A minority (17.4%) considered GCS < 8 an independent indication for intubation. For the alcohol intoxication case, 88% agreed that aspiration risk was present but only 11% agreed they commonly intubate. Only 17% agreed intubation was standard care, and only 0.8% felt their colleagues always intubate such patients. For the seizure case, 65% agreed aspiration risk existed but only 3% agreed they commonly intubate, 1% felt colleagues always intubated, and 5% agreed intubation was standard of care. Additional factors felt to compel intubation (394 total) and support non-intubation (366 total) were compiled and categorized; the most common themes emerging were objective evidence of emesis or aspiration, other standard indications for intubation, head trauma, co-ingestions, co-morbidities and clinical instability. Conclusion: It is acceptable and standard practice to avoid intubating a select subset of intoxicated and post-seizure emergency department patients despite aspiration risk. Most physicians do not view the dogma of “GCS 8, intubate” as an absolute indication for intubation in these patients. Future research is aimed at identifying key factors and evidence supporting intubation for the prevention of aspiration, as well as the development of a validated clinical decision rule for common emergency presentations.
P056: Gastric ultrasound in stable patients with decreased level of consciousness and recreational substance use -- are presumed full stomachs full?
Authors: Munn M. , Phillips C. , Laraya J. , Boivin-Arcouette G.
Published: May 2020

Introduction: Intoxicated patients with decreased Glasgow Coma Scale (GCS) are common presentations to emergency departments. These patients are often intubated due to presumed full stomachs and perceived aspiration risk. Gastric ultrasound (GUS) -- a simple, non-invasive and objective option -- could be applied to this problem. This pilot study uses GUS alongside usual care at a music festival; a bounded, intoxication-dense environment where airways are often managed using non-invasive airway strategies. We aim to (1) clarify the gastric contents of any intubated patients, and (2) assess if patients managed without intubation go on to have a lack of aspiration sequelae because of empty stomachs or in spite of full stomachs. Methods: A prospective cohort study was conducted at a multi-day music festival. Patients presenting to on-site medical services with GCS ≤ 13 and known or suspected substance use were included. Patients with trauma, instability, metabolic derangements or additional aspiration risk factors (eg morbid obesity, pregnancy) were excluded. Standard GUS was performed by a trained provider and results were categorized according to convention as FS (full stomach, ie solids or liquids >1.5mL/kg) or ES (empty stomach, ie empty or liquids <1.5mL/kg). Additional patient data were extracted from linked medical records post event. Results: 33 patients met inclusion criteria and 27 remained after exclusions were applied and consent obtained. 25 patients reported substance use and 19 polysubstance use. The FS group had 15 patients (7 solid & 8 liquid > 1.5), and the ES group had 12 patients (5 empty & 12 liquid < 1.5). The median low GCS documented for FS and ES was 7 and 11 respectively, and 10 patients total had a GCS of 8 or less (6 FS & 4 ES). No patients were intubated and all were managed conservatively according to usual care. 3 patients (2 FS, 1 ES) were transferred to hospital. No patients re-registered at medical for clinically significant aspiration. Conclusion: This pilot study demonstrates the potential utility of GUS in stratifying aspiration risk in intoxicated patients with decreased GCS. “Empty” stomachs might avoid intubation, while the implications and true risks of “full” stomachs for aspiration sequelae in the absence of intubation remain unclear. Due to the small numbers in this pilot study and the quoted GUS sensitivity (only 95%), further research is needed to evaluate the safe application of this modality to clinical decision-making in intoxicated patients.
P058: Accuracy of the trauma triage protocol Échelle québécoise de triage préhospitalier en traumatologie (EQTPT) in selecting patients requiring specialized trauma care
Authors: Mercier E. , Beaumont-Beaulieu R. , Malo C. , Tardif P. , Moore L. , Eramian D. , Nadeau A.
Published: May 2020

Introduction: This study aims to evaluate the accuracy of the Échelle québécoise de triage préhospitalier en traumatologie (EQTPT) to identify patients who will need urgent and specialized trauma care in the La Capitale-Nationale region, province of Quebec. Methods: A detailed review of prehospital and in-hospital medical charts was conducted for a sample of patients transported following a trauma by ambulance to one of the five CHU de Quebec's emergency departments (ED) between November 2016 and March 2017. Data related to the trauma mechanism, population, injuries sustained, diagnosis, intervention and patient outcomes were extracted. The study primary outcome was the use of at least one urgent and specialized trauma care defined as: admission to the intensive care unit (ICU), urgent surgery within less than 24 hours after arrival (excluding orthopedic surgery for one limb only), intubation in ED, angioembolization within 24 hours after ED arrival, activation of a massive transfusion protocol in the ED. Also, patients who died secondary to their trauma were also considered as requiring urgent care. Results: 902 patients were included. The mean age (SD) was 59 (28.5) years old, 494 (54.8%) were female. The main trauma mechanisms were falls (592 (65.6%)) followed by motor vehicle accident (201 (22%)). 367 (40.7%) patients were transported directly to the tertiary trauma centre from the field. 231 (25.6%) patients had at least one criteria included in the steps 1, 2 or 3 of the EQTPT. Subsequently, most patients (649 (71.9%) were discharged home from the ED while 177 (19.6%) patients were admitted to the hospital. 82 (9.1%) patients required urgent and specialized trauma care. Of these 82 patients, 27 patients (32%) were identified in step 1 of the protocol, 12 patients (14.6%) in step 2, 5 patients (6.1%) in step 3, 13 patients (15.9%) in step 4 and 2 patients (2.4%) in step 5 while 23 (28.0%) patients were not identified by any steps of the EQTPT protocol. Therefore, 44 (53.6%) of the patients requiring urgent and specialized trauma care were identified by the criteria proposed in the steps 1, 2 or 3. Conclusion: In this retrospective cohort study, the EQTPT was insensitive to identify trauma patients who will need prompt and complex trauma management. Studies are required to determine the factors that could help improve its accuracy.
P065: Out-of-hospital cardiac arrest patients eligible for extracorporeal cardiopulmonary resuscitation in Regina emergency departments
Authors: Lee B. , Sy E. , Clay A.
Published: May 2020

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rapidly evolving technology for clinical use in patients with refractory cardiogenic arrest. Out-of-hospital cardiac arrest (OHCA) is a common cause of unexpected death and has a low survival rate. There is increasing evidence that suggests better outcomes for (OHCA) patients, including improved neurological outcomes and survival rates, who are started on extracorporeal corporeal membrane oxygenation (ECMO) versus traditional resuscitation methods. Methods: We conducted a retrospective chart review of 200 out-of-hospital cardiac arrest patients presenting to Regina emergency departments from January 1, 2017 to March 31, 2019. Eligibility for ECPR was assessed using different clinical criteria from different ECPR programs (University of British Columbia, University of Michigan, and a hypothetical “Regina” criteria created for this study). Outcomes of the eligible patients were compared using descriptive statistics with SPSS version 22. Results: Between four different criteria, 15%, 9.5%, 7.5%, and 3.5% of patients were respectively eligible to receive ECPR. Of patients who met eligibility for all four criteria, 80% were male, the average age was 61 years old, the average Cerebral Performance score was 4.46, and 83% died in hospital. There was a low survival rate of eligible patients, with rates of 16%, 17%, 20%, and 28% in each group. The survival rate for all patients was 21% and the average CPC score was 4.35. Conclusion: The significant percentage of patients were eligible for ECPR upon presentation to Regina Emergency Departments. Patients who were eligible had low survival rates and poor neurological outcomes, suggesting that ECPR could prove to be a valuable clinical tool that could improve patient outcomes in Saskatchewan. There were considerable differences in patient eligibility percentages based on different criterion. Differences in inclusion/exclusion criteria, modifying the expected annual number of ECPR eligible OHCA patients, could provide valuable information on required resources and planning for implementation of an ECPR program in a smaller centre, such as Regina.
P066: A quality improvement project to improve access to automated external defibrillators in the Niagara region community
Authors: Chadwick R. , Elliott K. , Haworth R. , Kearney H. , Laviolette A.
Published: May 2020

Background: Over 35,000 Canadians lose their lives to cardiac arrest each year. CPR and automated external defibrillator (AED) use are modifiable factors. Survival rates drop by 7-10% each minute that defibrillation is delayed, and survival rates are less than 5% after 12 minutes of ventricular fibrillation which stresses the need for bystander AED use in out-of-hospital arrests. Niagara Region lacks a publicly accessible registry of AEDs. AED access is a major focus in King County, Washington which has higher survival rates and has all AEDs registered with Emergency Medical Services. Aim Statement: This project aims to log 100 or more AEDs within a year into a publicly accessible registry and to connect the registry information to medical trainees in the Niagara region and all employees of the Niagara Health System involved in patient care. Measures & Design: PulsePoint is an application used to register AEDs within the Niagara region. PulsePoint allows users to geotag AEDs while tracking data entries. Over 16 weeks, 4 PDSA cycles tested the effectiveness of logging methods for AEDs including opportunistic logging, daily emailed reminders, and contacting organizations with high likelihood of having an AED. Information about the project and registry was shared with residents and medical students in Niagara. A second phase of cycles involves relaying information to Niagara Health system employees and the medical community. A final cycle will target a broader group of local organizations with intermediate probability of having AEDs. Primary outcome measures include the numbers of regional AEDs logged and members reached by knowledge sharing cycles. Evaluation/Results: PulsePoint was found to be an effective, free, publicly accessible resource to log AEDs within the Niagara region. The initial round of 4 PDSA cycles added a total of 56 new AEDs within the region, which were logged into PulsePoint app and the Excel spreadsheet. Through the fourth PDSA cycle, 136 businesses were contacted and made aware of the project and the AED application. In addition,138 health-related colleagues and medical students were contacted to raise awareness. PDSA cycles five through eight are currently ongoing or in the planning stages. Discussion/Impact: Raising awareness among emergency services and sharing information about the registry to local CPR training providers will be paramount. Creating awareness of PulsePoint and installing AEDs in locations that currently lack such devices could ultimately improve cardiac arrest survival rates within Niagara Region.