bluuebunny/crossref_metadata_2025 huggingface dataset:
LO46: The impact of rapid antigen detection testing on antibiotic prescription for acute pharyngitis: a systematic review and meta analysis
Authors: Anjum O. , Joo P.
Published: May 2017

Introduction: Acute pharyngitis is a common reason for primary care or emergency department visits, often resulting in antibiotic prescription. Rapid antigen detection tests (RADT) are routinely used to diagnose Group A Streptococcus (GAS) pharyngitis. However, due to its low sensitivity, patient pressures and conflicting guidelines, the RADT often complicates management decisions. Our aim was to assess the impact of RADT in patients presenting with acute GAS pharyngitis on the antibiotic prescription rate and appropriateness of antibiotic management. Methods: We systematically searched Medline, Embase, and Cochrane databases from 1980 to June 2016. Studies were selected according to a predefined PRISMA protocol and data extracted by two independent reviewers. Prospective and retrospective studies that evaluated the impact of RADT on antibiotic prescription for pharyngitis were included. Study quality was assessed using Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale. Our main outcome was a dichotomous measure of antibiotic prescription, with or without RADT availability. Studies were combined if there was low clinical and statistical heterogeneity (I2<30%). Bivariate Mantel-Haenszel random effects model was used to perform meta analyses using SPSS 22 and Revman 5. Results: We identified 4003 studies: 139 were selected for full text review; 10 met our inclusion criteria (N=10859 participants, median age 31 years, 56.7% female). Mean antibiotic prescription rate in the RADT and control arm was 38.2% (SD 15.6) and 55.9% (SD 16.3), respectively. The use of RADT was associated with lower antibiotic prescription rate in both adults (OR=0.60 [95% CI 0.45-0.80], I2=8%, N=1407) and pediatrics (OR=0.49 [95% CI 0.44-0.55], I2=5%, N=976). There was no overall difference (p<0.3) in antibiotic prescription rate among disease severity (Centor scores 1-4). The use of RADT did not significantly impact the appropriateness of antibiotic management (OR=1.15 95% CI 0.94-1.5). Conclusion: The use of RADT is associated with a reduction in antibiotic prescription for patients with GAS pharyngitis without an increase in appropriate antibiotic use. Despite low prevalence of the disease in the population, antibiotic prescription rates are still high. These findings suggest great potential for antibiotic stewardship and reevaluation of current guidelines for managing GAS pharyngitis.
LO54: A descriptive analysis of ED length of stay of admitted patients ‘boarded’ in the emergency department
Authors: Salehi L. , Phalpher P. , Valani R.
Published: May 2017

Introduction: Previous studies have shown a link between Emergency Department (ED) overcrowding and worse clinical outcomes, increased risk of in-hospital mortality, higher costs, and longer times to treatment. Prolonged ED Length of Stay (LoS) of admitted patients awaiting a bed on in-patient units has been identified as a major driver of ED overcrowding. The purpose of this study is to provide a descriptive analysis of ED LoS among admitted patients, and determine the impact of prolonged ED LoS on total hospital in-patient length of stay (IP LoS). Methods: We conducted a single-site retrospective study for the period between January 1-December 31, 2015 at a very high volume community hospital. All patients aged ≥18 years admitted from the ED to acute in-patient Medicine units were identified. We carried out overall descriptive analysis (including analysis of day-of-the-week variability) on ED LoS. The mean total IP LoS for those patients with ED LoS<12 hours, 12-24 hours, and ≥24 hours were calculated and analyzed using ANOVA and Tukey HSD tests. Results: A total of 6,961 individuals were admitted to the medical units over the 12-month period. The median and mean ED LoS for admitted patients were 22.9 hrs (IQR: 13.9 hrs- 33.1 hrs) and 25.6 hrs respectively. Using ANOVA, there was a statistically significant difference in means of ED LoS as a function of the day of the week (p<0.0001), with Mondays having the highest mean ED LoS (27.6 hrs), and Fridays having the lowest (23.1 hrs). The mean IP LoS for those with ED LoS<12 hours, 12-24 hours, and ≥24 hours, were 6.8 days, 6.9 days, and 8.5 days respectively, with a statistically significant difference between group means (p<0.0001). Multiple pairwise comparisons of group means showed a statistically significant (p<0.05) difference between mean IP LOS of those with an EDLOS≥24 hours and those with an EDLOS<24 hours. Conclusion: Preliminary results indicate that ED LoS≥24 hours among admitted patients was associated with an increase in total IP LoS.*In the next 1-2 months, we intend to explore the role of other independent variables (age, sex, comorbidity, isolation status, and telemetry) on total ED LoS, and its association with IP LoS.
MP03: Predicting survival after pediatric out-of-hospital cardiac arrest
Authors: Drennan I. , Thorpe K. , Cheskes S. , Mamdani M. , Scales D. , Guerguerian A. , Morrison L.J.
Published: May 2017

Introduction: Pediatric out-of-hospital cardiac arrest (OHCA) is unique in terms of epidemiology, treatment, and outcomes. There is a paucity of literature examining predictors of survival to help guide resuscitation in this population. Objective: The primary objective was to examine predictors of survival to hospital discharge. The secondary objective was to determine the probability of return of spontaneous circulation (ROSC) over the duration of resuscitation. Methods: We performed a retrospective cohort study of non-traumatic OHCA (<18 years) treated by EMS from the Toronto Regional RescuNET Epistry-Cardiac Arrest database from 2006 to 2015. We used competing risk analysis to calculate the probability of ROSC over the duration of resuscitation. We then used multivariable logistic regression to examine the role of Utstein factors and duration of resuscitation in predicting survival to hospital discharge. Candidate variables were limited to Utstein factors and duration of resuscitation due to the number of events. We used area under the receiver operating characteristic (ROC) curve (AUC) to determine the predictive ability of our logistic regression model. Results: A total of 658 patients met inclusion criteria. Survival to discharge was 10.2% with 70.1% of those children having a good neurologic outcome. The overall median time to ROSC was 23.9 min. (IQR 15.0,36.7). However, the median time to ROSC for survivors was significantly shorter than the time to ROSC for patients who died in hospital (15.9 (IQR 10.6 to 22.8) vs. 33.2 (IQR 22.0 to 48.6); P value <0.001). There was a decrease in the odds of survival of 14% per minute during the first 25 minutes of cardiac arrest. Older age (OR 0.9, 95% CI 0.86,0.99), and longer duration of resuscitation (OR 0.9, 95% CI 0.88,0.93) were associated with worse outcome while initial shockable rhythm (OR 5.8, 95% CI 2.0,16.5), and witnessed arrests (OR 2.4, 95% CI 1.10,5.30) were associated with improved patient outcome. The AUC for the Utstein factors was fair (0.77). Including duration of resuscitation improved the discrimination of the model to 0.85. Conclusion: Inclusion of duration of resuscitation improved the performance of our model compared to Utstein factors alone. However, our results suggest there are a number of other important factors for predicting patient outcome from pediatric OHCA.
MP12: Acute asthma presentations to emergency departments in Alberta: an epidemiological analysis of presentations
Authors: Alexiu C. , Krebs L. , Villa-Roel C. , Holroyd B.R. , Ospina M. , Pryce C. , Bakal J. , Jelinski S.E. , Innes G. , Lang E. , Rowe B.H.
Published: May 2017

Introduction: Asthma is a chronic condition and exacerbations are a common reason for emergency department (ED) presentations across Canada. The objective of this study was to characterize and describe acute asthma presentations over a five-year period. Methods: Administrative health data for Alberta from 2011-2015 was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) acute asthma (ICD-10-CA: J45) ED presentations. All presentations to an Alberta ED with a primary or secondary diagnosis of acute asthma were eligible for inclusion. Presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1 were excluded. Data from NACRS were linked with a provincial diagnostic imaging database. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, a total of 51,269 (~10,000/year) acute asthma presentations were made by 34,481 patients (~0.3 presentations per patient per year). The median age was 35 years (IQR: 25, 49 years) and more patients were female (57.2%). Few patients arrived to the ED by ambulance (6.5%) and the most frequent CTAS score was 3 (43.5%). The majority of these patients (77%) had a primary diagnosis of asthma in the ED. Differences were explored between those with a primary asthma diagnosis and those with a secondary diagnosis (e.g., ambulance arrival, length of stay, hospital admission, etc.). Although differences were statistically significant, no clinically relevant differences were identified. Patients with asthma most frequently had a co-diagnosis of acute upper respiratory infection (6.2%); other co-diagnoses included bronchitis (4.7%), pneumonia (3.7%), heart failure (0.18%), pulmonary embolism (0.15%), and pneumothorax (0.03%). For 39.3% of patients, ED management included chest x-ray. The majority of patients were discharged from the ED (92.2%) following a median length of stay of 2.2 hours (IQR: 1.2, 3.8 hours). Conclusion: Acute asthma remains an important ED presentation in Alberta and the absolute frequency of presentations has remained relatively stable over the past five years. Frequency of chest x-ray ordering is high and represents a target for future interventions to reduce ionizing radiation exposure, improve patient flow and reduce healthcare costs.
MP19: Comparison of the psychometric properties of the VAS, FPS-R and CAS in the pediatric emergency department
Authors: Ali S. , Le May S. , Plint A. , Ballard A. , Khadra C. , Mâsse B. , Auclair M. , Neto G. , Drendel A.L. , Villeneuve E. , Parent S. , McGrath P. , Gouin S.
Published: May 2017

Introduction: Appropriate pain management relies on the use of valid, reliable and age-appropriate tools that are validated in the setting in which they are intended to be used. The aim of the study was to assess the psychometric properties of pain scales commonly used in children presenting to the pediatric emergency department (PED) with an acute musculoskeletal injury. Methods: Convergent validity was assessed by determining the Spearman’s correlations and the agreement using the Bland-Altman method between the Visual Analogue Scale (VAS), Faces Pain Scale-Revised (FPS-R) and Color Analogue Scale (CAS). Responsiveness to change was determined by performing the Wilcoxon signed-rank test between the pre-post analgesia mean scores. Reliability of the scales was estimated using relative (Spearman’s correlation, Intraclass Correlation Coefficient) and absolute indices (Coefficient of Reliability). Results: A total of 495 participants was included in the analyses. Mean age was 11.9 ±2.7 years and participants were mainly boys (55.3%). Correlation between each pair of scales was 0.79 (VAS/FPS-R), 0.92 (VAS/CAS) and 0.81 (CAS/FPS-R). Limits of agreement (80%CI) were -2.71 to 1.27 (VAS/FPS-R), -1.13 to 1.15 (VAS/CAS) and -1.45 to 2.61 (CAS/FPS-R). Responsiveness to change was demonstrated by significant differences in mean pain scores, among the three scales, between pre- and post-medication administration (p<0.0001). ICC and CR estimates suggested acceptable reliability for the three scales at 0.79 and ±1.49 for VAS, 0.82 and ±1.35 for CAS, and 0.76 and ±1.84 for FPS-R. Conclusion: The scales demonstrated good psychometric properties with a large sample of children with acute pain in the PED. The VAS and CAS showed a stronger convergent validity, while FPS-R was not in agreement with the other scales. Clinically, VAS and CAS scales can be used interchangeably to assess pain intensity of children with acute pain.
MP35: The CanadiEM Junior Editor Program: Integrating medical students and junior residents into a dedicated FOAMed training program
Authors: Bravo M. , Carey R. , Nguyen-Dinh D. , Chan T.M. , Thoma B.
Published: May 2017

Introduction/Innovation Concept: Free Open Access Medical education (FOAM) is a rapidly emerging medium for the dissemination of medical knowledge, especially in Emergency Medicine. However, the most contributors to FOAM are EM attendings who write on established platforms which they also maintain. EM learners have difficulty breaking into this quickly evolving field. In an effort to encourage FOAM involvement of trainees early in their careers, CanadiEM recruited 10 junior residents and medical students with the purpose of developing the skills necessary to contribute to FOAM. These Junior Editors actively participate in the blog workflow, developing writing, editorial, and management skills necessary to operate a high-traffic EM website. Methods: Potential candidates were recruited by placing an advertisement and application on the CanadiEM website. 10 medical students or junior residents were invited to online group video interviews and were all accepted as Junior Editors (JE). Senior CanadiEM staff held online training sessions for all new JEs on how to use Wordpress to create, edit and publish posts, as well as basics in Search Engine Optimization. The junior editors collaboratively developed an instructional document containing the information they learned during these sessions. JEs then volunteered for editorial jobs via an online messaging system (Slack) as they became available. After uploading the draft of each post, the final products are reviewed by senior Editor and feedback was given to each JE. Curriculum, Tool, or Material: All JEs have learned to use the Wordpress blogging platform to create, edit, and upload posts; optimize blog posts for search engines. Following their own interests, some JEs have also learned to edit podcasts, promote the blog on social media resources (Twitter and Facebook), create infographics, and copy-edit blog posts. Conclusion: After 8 months, the JE program has yielded 6 very active editors who maintain a strong blog workflow, have well-developed social media skills, and are actively involved in developing their own content for future posts. The JE program is a strong pathway to introduce medical trainees to both the technical and creative aspects of FOAM and serves as a novel approach to transition students from passive utilization of online content to active contributors.
P013: What are the short-term goals of patients presenting the emergency department with an acute mental health complaint?
Authors: Barbic S. , MacEwan W.G. , Leon A. , Chau S. , Salehmohamed Q. , Kim B. , Khamda B. , Mernoush V. , Khoshpouri P. , Osati F. , Barbic D.
Published: May 2017

Introduction: In the last year, Canada published its Strategy for Patient-Oriented Research (SPOR) to ensure that patients receive the right treatment at the right time. Approximately, one in five Canadians will experience a mental illness in their life time, with many presenting to the Emergency Department (ED) as their entry point into the system. In order to improve patient outcomes and focus on patient-identified priorities, the aim of this study was to identify the short-term goals of patients with an acute mental health complaint (AMHC) presenting to the ED. Methods: We prospectively recruited a convenience sample of patients presenting to an inner city, academic ED with an annual census of 85,000 visits. Patients provided written informed consent and completed a survey package that included questions about employment intentions and short-term life goals. We collated the goals and used a content analysis to summarize the frequency of themes that emerged. Results: This study reports on the preliminary data from 108 of the targeted 200 patients (mean age 39.7 ±13.6 years; 65% male). A total of 75% of participants reported being unemployed, 84% of whom reported that they would like to gain some form of employment in the near future. Over half the sample (52%) identified that they were not satisfied with their current housing situation. In addition to improving housing and obtaining work, improving mental health (n=34), improving relationships with family or friends (n=27), going back to school (n=22) and managing addiction problems (n=20) were identified as the most common short-term goals. Other goals/priorities included improving physical health, traveling, exercising, and eating better. Conclusion: This study provides new information about the priorities of adults presenting with AMHC to the ED. It also offers insight into how to collaborate with patients to build sustainable, accessible, and coordinated care pathways that can bring about positive changes in their lives. This information can be used to compliment current care for mental health problems, ensuring greater quality, accountability, and continuity of care for this vulnerable patient group.
P017: A time-driven activity-based costing method to estimate health care costs in the emergency department
Authors: Berthelot S. , Mallet M. , Baril L. , Dupont P. , Bissonnette L. , Stelfox H. , Émond M. , Blais S. , Vezo A. , Létourneau M. , Côté S. , Bécotte G. , Lafrenière M. , Moore L.
Published: May 2017

Introduction: Poor physicians’ knowledge of health care costs has been identified as an important barrier to improving efficiency and reducing overuse in care delivery. Moreover, costs of tests and treatments estimated with traditional costing methods have been shown to be imprecise and unreliable. We estimated the cost of frequent care activities in the emergency department (ED) using the time-driven activity-based costing (TDABC) method. Methods: We conducted a TDABC study in the ED of the CHUL, Québec city (77000 visits/year). We estimated the cost of all potential care activities (e.g. triage) provided to adult patients with selected urgent (e.g. pulmonary sepsis) and non urgent (e.g. urinary tract infection) conditions frequently encountered in the ED. Following Lean management principles, process maps were developed by a group of ED care providers for each care activity to identify human resources, supplies and equipment involved, and to estimate the time required to complete each process. Resource unit cost (e.g. cost per minute of a nurse) and overhead rate were calculated using financial information from fiscal year 2015-16. Estimated cost of each care activity (e.g. chest X-ray) including physicians’ charges was calculated by summing overhead allocation and the cost of each process (e.g. disinfection of the X-ray machine) as obtained by multiplying the resource unit cost by the time for process completion. Results: Process maps were developed for 14 conditions and 68 ED care activities. We estimated the costs of activities (CAN$) related to nursing (e.g. urinalysis and culture triage ordering $14.70), clerk tasks (e.g. patient registration $3.40), physicians (e.g. FAST scan $20.90), laboratory testing (e.g. CBC $6.30), diagnostic imaging (e.g. abdominal CT scan $146.50), therapy (e.g. 5 mg of iv morphine $20.40), and resuscitation (rapid sequence intubation with ketamine and succinylcholine $146.40). Overall, emergency physicians’ charges, personnel salaries and overheads accounted for 38%, 22% and 16% of all ED care costs, respectively. Conclusion: Our results represent an important step toward increasing emergency physicians’ awareness on the real cost of their interventions and empowering them to adopt more cost-effective practice patterns.
P018: Prehospital diversion of mental health patients to a mental health center vs the emergency department: safety and compliance of an EMS direct transport protocol
Authors: Bismah V. , Prpic J. , Michaud S. , Sykes N
Published: May 2017

Introduction: Prehospital transport of patients to an alternative destination (diversion) has been proposed as part of a solution to overcrowding in emergency departments (ED). We evaluated compliance and safety of an EMS protocol allowing paramedics to transport medically stable patients with psychiatric issues directly to an alternate facility [Crisis Intervention (CI)], bypassing the ED. Patients were eligible for diversion if they were ≥18 years old, classified as CTAS III-IV, scored <4 on the Prehospital Early Warning (PHEW) score, and did not have any vital sign parameters in a danger zone (as per PHEW score criteria). Methods: A retrospective analysis was conducted on patients presenting to Sudbury EMS with behavioural or psychiatric issues. Data was abstracted from EMS reports, hospital medical records, and discharge forms from CI. Protocol compliance was measured using missed protocol opportunities (patients eligible for diversion but taken directly to the ED) and protocol noncompliance rates; protocol safety was measured using protocol failure (presentation to ED within 48 hours of appropriate diversion) and patient morbidity rates (hospital admission within 48 hours of diversion). Data was analysed qualitatively and quantitatively using proportions. Results: EMS responded to 695 calls with psychiatric complaints. Of the 650 taken directly to the ED, 18 met diversion criteria; these were missed protocol opportunities (3%). 45 patients were diverted. There was protocol noncompliance in 36 cases (80%), but 34 were due to incomplete recording of vital signs. There were direct protocol violations in only 2 cases (4%). There was protocol failure in 3 cases (33%), and patient morbidity in 8 cases (18%). No patients died within 48 hours of diversion. Conclusion: EMS providers were highly compliant with the protocol when transporting patients directly to the ED. There were high levels of protocol non-compliance in diverting patients to CI, though this is largely attributed to incomplete recording of vital signs; direct protocol violations were low. The protocol provides moderate levels of safety in diverted patients. Broader implementation of a diversion protocol could reduce the volume of mental health patients seen in the ED, and improve quality of care received by this patient population.
P023: Emergency department data provides a realistic count of pedestrian injuries
Authors: Brubacher J.R. , Sutton G. , Lam C. , Trajkovski A. , Yip R. , Liu T. , Chan H.
Published: May 2017

Introduction: Walking as a form of active transportation is promoted by health professions and environmentalists alike. While the health benefits are indisputable, active transportation is not without risk. Pedestrians are vulnerable road users who often suffer serious injuries especially when involved with collisions with motor-vehicles. While pedestrian injuries involving motor-vehicles are captured in road trauma surveillance systems based on police crash reports, non-collision injuries in this population may be caused by poorly designed infrastructure but are seldom counted as road trauma. This gap hinders road improvement efforts aiming to increase safety for all road users. This study aims to address this knowledge gap. Our objective is to study the profile and circumstances of injuries in pedestrians presenting to ED. Methods: This was a cross-sectional historical chart review study. All injured patients attending our ED are electronically flagged according to mechanism of injury. We reviewed the medical charts of all ED visits flagged as “Pedestrian” or “Fall” to identify all injured pedestrians (defined in this study as anyone walking on a public roadway or getting on/off public transportation). All pedestrian injuries occurred in 2015 were included for chart review. Results: In 2015, a total of 6192 ED presentations were flagged as pedestrian (n=436) or fall (n=5756), and 1108 of these met our inclusion criteria. Of these, 181 (16%) were admitted to hospital. Older pedestrians (≥70 yrs) had a higher hospital admission rate (78/303; 27%) compared to younger ones (<70 yrs: 103/805; 13%). Collision with motor vehicles (MVCs) resulted in only 25% of pedestrian injuries while fall (or tripping) accounted for about 72%. MVC related injuries were more common in younger pedestrians (29% vs 13%) whereas fall related injuries occurred more in older pedestrians (85% vs 67%). The most commonly sustained injuries among the fallers were abrasions followed by fractures. Conclusion: Police crash reports (which capture only MVC related pedestrian injuries) or hospital admission data (which miss those who are treated and released from ED) do not capture all cases of pedestrian injury. ED visit data provides a more realistic count of pedestrian injuries. More pedestrian injuries are caused by falls than by MVCs and policymakers should pay more attention to fall prevention strategies for older pedestrians outside their home environment.
P040: Epidemiology of gun related injuries among Canadian children and youth from 2005-2013: a CHIRPP study
Authors: Cox C.M. , Stewart S. , Hurley K.F.
Published: May 2017

Introduction: Gun related injuries were last reported by the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) in 2005. Since that time, Canadian gun control is less stringent and non-powder guns are increasingly popular. We aim to describe trends in pediatric gun related injuries and deaths since 2005. Methods: This is a retrospective review of CHIRPP data. The dataset included pediatric (age 0-19 years) gun-related injuries and deaths reported by participating CHIRPP emergency departments (ED) from 2005-2013. Variables were tested using Fisher’s exact test and simple linear regression. Results: There were 421 records of gun-related injuries in the database. Three hundred and twenty-nine occurred from use of non-powder guns, 85 occurred from use of powder-guns, and in 7 cases the type of gun was not clear. The number of gun-related injuries per 100 000 ED visits remained stable from 2005-2013 with a male predominance (n=366, 87%). Most injuries resulted from non-powder guns and were unintentional. Injuries most often occurred in the context of recreation (n=181) and sport (n=51). One hundred fifty four eye injuries were reported, 98% of which were from a non-powder gun. Forty-six individuals required admission to hospital and 2 died in the ED. Nine of 10 intentional self-harm injuries were inflicted with a powder gun. Conclusion: This study describes the injuries and circumstances in which pediatric gun-related injury and death occur in Canada. Unintentional injuries caused by non-powder guns were most common. Though less fatal than powder guns, non-powder guns can still cause life-altering eye injuries. This evidence can inform injury prevention programs to target specific circumstances in which the pediatric population is most vulnerable.
P049: Modelling and manufacturing of a 3D printed trachea for cricothyroidotomy simulation
Authors: Doucet G. , Ryan S.
Published: May 2017

Introduction: Most current cricothyroidotomy simulation models are either expensive or low fidelity and limit the learner to an unrealistic simulation experience. The goal of this project is to innovate current simulation techniques by 3D printing anatomically accurate trachea models. By doing so emergency cricothyroidotomy simulation can be accessible, high fidelity, cost effective and replicable. Methods: 3D modelling software was used in conjunction with a desktop 3D printer to design and manufacture an anatomically accurate model of the cartilage within the trachea (thyroid cartilage, cricoid cartilage, and the tracheal rings). The initial design was based on dimensions found in studies measuring the dimensions of tracheal anatomy. This ensured an appropriate anatomical landmark design was achieved. Several revisions of the model were designed and qualitatively assessed by medical and simulation professionals to ensure anatomical accuracy that exceeded that of the currently used, low cost, cricothyroidotomy simulation model in St. John’s. Results: Using an entry level desktop 3D printer, a low cost tracheal model was successfully designed that can be printed in under 3 hours. Due to its anatomical accuracy, flexibility and durability, this model is ideal for use in emergency medicine simulation training. Additionally, the model can be assembled in conjunction with a membrane to simulate tracheal ligaments and skin for appearance. Conclusion: The end result is a high fidelity simulation that will provide users with an anatomically correct model to practice important skills used in emergency airway surgery, specifically land marking, incision and intubation. This design is a novel, easy to manufacture, replicable, low fidelity trachea model that can be used by educators with limited resources such as those in rural and remote areas.
P051: Does knowledge of the Canadian CT Head Rules impact the frequency of CT’s ordered?
Authors: Duyvewaardt H.C. , Ertel M. , Angel-Mira J. , Parker  , Kandola N. , Cheyne M. , Brar R. , Sidhu H.
Published: May 2017

Introduction: The Canadian Computed Tomography Head Rules (CCTHR) is a validated and well-known head injury clinical decision rule that allows Emergency Room Physicians (ERPs) to determine which patients are most likely to benefit from a diagnostic CT. However, this clinical decision rule is not uniformly adhered to and a number of preventable CT scans are ordered. Choosing Wisely Canada has ranked decreasing unnecessary head CT scans as the number one priority for Emergency Departments (ED). As such, the purpose of this study was to investigate if an educational intervention for ERPs would increase adherence to the CCTHR. Methods: In September 2015 the CCTHR were presented and discussed at three ED departmental meetings at Kelowna General Hospital (KGH) a large tertiary hospital in the interior of British Columbia, Canada. Educational materials were distributed to the ERPS and a CTTHR checklist was made available throughout the ED. Rates of adherence to the CCTHR criteria were calculated from MHI patients that were seen in the four years prior to the educational intervention and were compared to rates of adherence for patients 12 months post educational intervention. Only patients that agreed to participate in the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were included in this analysis. Differences in adherence rates were tested using the chi-squared test. Results: 477 patients were included in the analysis for the pre-education cohort (control) and 257 for the post-education cohort(intervention). In the control cohort, 348 of the 477 (73%) of the patients were managed in accordance to the CCTHR compared to 194 of the 257 (75%) in the intervention cohort. There was no statistically significant difference in rates of adherence (p=0.457).In the control cohort, 44 of the 321 (14%) of patients received a CT that did not meet any CCTHR criteria compared to 15 of the 163 (9%) in the intervention cohort. The overall CT imaging rate was 24% in each patient cohort. Conclusion: Although adherence rates between the two cohorts were not statistically different, a greater proportion of patients had a CTAS of 2 or 3 and met criteria in the intervention cohort suggesting a higher level of acuity. Imaging rates remained constant at 24%, which was lower than expected if there was full adherence to the CCTHR. Further study is required to determine if educational interventions can improve adherence to the CCTHR.
P060: Imaging practices of emergency physicians for low risk non-traumatic low back pain
Authors: Hiranandani R. , MacKenzie M. , Wang D. , Lang E.
Published: May 2017

Introduction: Included in the first list of recommendations from the Choosing Wisely Canada (CW) Emergency Medicine (EM) group was to avoid ordering lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. It has been suggested that these lumbosacral radiographs lead to unnecessary ionizing radiation and increase emergency department (ED) wait times without improving patient outcomes. This study evaluates lumbosacral imaging practices of emergency physicians (EPs) in four urban EDs. Methods: Data was retrospectively collected from patients, ages 18-60 and CTAS codes 2-5, who presented with non-traumatic LBP from April 1, 2014 to March 31, 2016 to four urban EDs. The time frame included both pre- and post-CW recommendation. Patients considered high risk, specifically with PTT >40 s or INR >1.2 s, neurology/neurosurgery/spine consults, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish lumbosacral radiograph usage rates for non-traumatic LBP. The secondary outcome was to identify factors that influenced lumbosacral spine imaging. Factors analyzed included patient age, patient sex, ED wait times, physician age, physician experience, and physician sex. Statistical significance was determined by chi-squared analysis. Results: The data from 3140 low-risk patients showed that 16.5% of the patients received lumbosacral radiographs. Physician variation in X-ray ordering was 0% to 85.7% (IQR 4.6 to 25%). There was a significant difference between the X-rays ordered at each site (site 1 (23.1%)>site 2 (17.2%)>site 3 (14.9%)>site 4 (11.3%), p<0.001). CCFP-EM licensed physicians (17.9%) ordered more X-rays compared to licensed physicians (13.7%, p<0.001). Time of presentation, physician sex, and patient sex did not affect the imaging practices. There was a trend towards decreased ordering of X-rays (17.6% vs. 15.1%, p=0.06) post-CW recommendation. Conclusion: Considerable variation exists in the ordering practices of Calgary EPs; however, on average they are choosing wisely in terms of ordering imaging for non-traumatic LBP.
P065: The history of emergency medicine in Ottawa
Authors: James D. , Lamb S. , Frank J.R.
Published: May 2017

Introduction/Innovation Concept: There is a paucity of peer-reviewed works investigating the History of Emergency Medicine (EM) in Canada, and none examining a single centre. This study analyzed the academic and clinical evolution of EM in the City of Ottawa from its origins to present. Methods: The study comprised primary and secondary historical research and an oral history methodology. A literature review was performed on the following databases: PubMed, Medline, EMBASE, JSTOR, Web of Science, Historical Abstracts; five medical history journals were also searched. Data were collected from City of Ottawa Archives, Archives of the Sisters of Charity of Ottawa, The Ottawa Hospital Libraries, University of Ottawa Libraries, RCPSC and CFPC Archives, Historical Society of Ottawa documents, Ottawa newspaper archives, and professional correspondences. The oral history component consisted of formal interviews with seven practicing and retired Emergency Physicians in Ottawa. Ethics approval was not required though consent was obtained from respondents. Curriculum, Tool, or Material: The literature review yielded the following: PubMed: 218 results, 180 excluded for non-relevance, 3 papers included in analysis. Historical Abstracts: 1 result, overlap with PubMed. Other databases and medical history journals yielded no papers. Along with extensive archival data, these results were used to construct a detailed timeline of EM history in Ottawa and Canada more broadly. Residency training in EM in Ottawa was initiated in 1972 at the impetus of the Board of the Ottawa Civic Hospital. Two main themes recurred in the interviews: resistance from existing specialties to EM becoming a specialty, and early Emergency Rooms staffed by the least trained people treating the least differentiated patients. Early EM physicians were not viewed positively by other specialists. Conclusion: Pioneering EM physicians were forced to validate the specialty as distinct, rigorous, and credible. In Ottawa this was achieved by developing strong core academics and research. Nationally, this has been instrumental in establishing EM as a viable standalone academic specialty. Modern consult pushback may have evolved from existing specialists fighting against the creation of EM combined with their negative perception of EM physicians. These data could be incorporated into learning modules for EM residency academic programs, and the methods applied to other centres.
P069: Prehospital amiodarone use could improve favorable neurological recovery among patients with out-of-hospital shockable cardiac arrest
Authors: Kawano T. , Scheuermeyer F.X. , Christenson J. , Stenstrom R. , Grunau B.E.
Published: May 2017

Introduction: Amiodarone may be used for shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), but the effect of prehospital use upon neurological outcomes still unclear. Methods: A prospective province-wide, population based observational study was conducted from January 2006 to March 2016. Adult emergency medical service-treated non-traumatic OHCA patients who received at least one electric defibrillation were included. Amiodarone was administered to patients with VF/ pVT by paramedics based on their clinical assessment, according to provincial guidelines. The outcome of interest was favorable neurological outcomes to hospital discharge, defined as modified Rankin scale of 3 or less. Multivariable logistic regression was performed to compare the proportion of patients with the primary outcome between amiodarone and non-amiodarone groups, further stratified by the number of electrical defibrillation. In addition, to mitigate the potential selection bias, the same logistic regression was conducted in 1:1 propensity score matched groups adjusting for baseline covariates. Results: Of 3,374 overall OHCA patients, 915 (27.1%) were managed with amiodarone. In the amiodarone group, 150 / 915 (16.4 %) patients had a favorable neurological outcome, compared to 455/2,459 (18.5%) in the non-amiodarone group (crude odds ratio [OR] 0.86, 95% CI 0.71 to 1.06). In the multiple logistic regression model, prehospital amiodarone was associated with increased probability of favorable neurological outcomes (adjusted OR 2.11, 95% CI 1.46 to 3.05). With stratification by the number of electrical defibrillation performed, amiodarone treated group showed higher probability of favorable neurological outcomes (1 or 2: adjusted OR 2.71, 95% CI 1.33 to 5.50, 3 and more: adjusted OR 1.67, 95% CI 0.99 to 2.39). Similarly, in 1:1 propensity matched cohort including 882 OHCA patients, the adjusted association persisted (adjusted OR 2.14, 95% CI 1.33 to 3.44). Conclusion: Prehospital administration of amiodarone to non-traumatic OHCA patients was associated with better neurological recovery, especially in those who received fewer electrical defibrillations.
P070: Mixed effectiveness of emergency department diversion strategies: a systematic review
Authors: Kirkland S.W. , Soleimani A. , Rowe B.H. , Newton A.S.
Published: May 2017

Introduction: Diverting patients away from the emergency department (ED) has been proposed as a solution for reducing ED overcrowding. The objective of this systematic review is to examine the effectiveness of diversion strategies designed to either direct patients seeking care at an ED to an alternative source of care. Methods: Seven electronic databases and grey literature were searched. Randomized/controlled clinical trials and cohort studies assessing the effectiveness of pre-hospital and ED-based diversion interventions with a comparator were eligible for inclusion. Two reviewers independently screened the studies for relevance, inclusion, and risk of bias. Intervention effects are reported as proportions (%) or relative risks (RR) with 95% confidence intervals (CI). Methodological and clinical heterogeneity prohibited pooling of study data. Results: From 7,306 citations, ten studies were included. Seven studies evaluated a pre-hospital diversion strategy and three studies evaluated an ED-based diversion strategy. The impact of diversion on subsequent health services was mixed. One study of paramedic practitioners reported increased ED attendance within 7 days (11.9% vs. 9.5%; p=0.049) but no differences in return visits for similar conditions (75.2% vs. 72.1%; p=0.64). The use of paramedic practitioners was associated with an increased risk of subsequent contact with health care services (RR=1.21, 95% CI 1.06, 1.38), while the use of deferred care was associated with no increase in risk of subsequently seeking physician care (RR=1.09, 95% CI 0.23, 5.26). While two studies reported that diverted patients were at significantly reduced risk for hospitalization, two other studies reported no significant differences between diverted or standard care patients. Conclusion: The evidence regarding the impact of pre-hospital and ED-based diversion on ED utilization and subsequent health care utilization is mixed. Additional high-quality comparative effectiveness studies of diversion strategies are required prior to widespread implementation.
P072: Exploring definitions of “unnecessary care” in emergency medicine: a qualitative analysis of physician survey responses
Authors: Krebs L. , Gaudet L. , Chartier L.B. , Holroyd B.R. , Dowling S. , Cheng A.H. , Villa-Roel C. , Campbell S.G. , Couperthwaite S. , Rowe B.H.
Published: May 2017

Introduction: Recently, campaigns placing considerable emphasis on improving emergency department (ED) care by reducing unnecessary tests, treatments, and/or procedures have been initiated. This study explored how Canadian emergency physicians (EPs) conceptualize unnecessary care in the ED. Methods: An online 60-question survey was distributed to EP-members of the Canadian Association of Emergency Physicians (CAEP) with valid emails. The survey explored respondents awareness/support for initiatives to improve ED care (i.e., reduce unnecessary tests, treatments and/or procedures) and asked respondents to define “unnecessary care” in the ED. Thematic qualitative analysis was performed on these responses to identify key themes and sub-themes and explore variation among EPs definitions of unnecessary care. Results: A total of 324 surveys were completed (response rate: 18%); 300 provided free-text definitions of unnecessary care. Most commonly, unnecessary ED care was defined as: 1) performing tests, treatments, procedures, and/or consults that were not indicated or potentially harmful (n=169) and/or 2) care that should have been provided within a non-emergent context for a non-urgent patient (n=143). Emergency physicians highlighted the role of system-level factors and system failures that result in ED presentations as definitions of unnecessary care (n=69). They also noted a distinction between providing necessary care for a non-urgent patient and performing inappropriate/non-evidenced based care. Finally, a tension emerged in their description of frustration with patient expectations (n=17) and/or non-ED referrals (n=24) for specific tests, treatments, and/or procedures. These frustrations were juxtaposed by participants who asserted that “in a patient-centred care environment, no care is unnecessary” (Participant 50; n=12). Conclusion: Variation in the definition of unnecessary ED care is evident among EPs and illustrates that EPs’ conceptualization of unnecessary care is more nuanced than current campaigns addressing ED care improvements represent. This may contribute to a perceived lack of uptake or support for these initiatives. Further exploring EPs perceptions of these campaigns has the potential to improve EP engagement and influence the language utilized by these programs.
P097: High-risk clinical features for acute aortic syndrome
Authors: Ohle R. , Wells G.A. , Perry J.J. , Um S.W.
Published: May 2017

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. The objective of our study was to assess the diagnostic accuracy of high risk historical, examination and basic investigative features for AAS, in confirmed cases of AAS and a low risk control group in order to address the spectrum bias in previous diagnostic accuracy studies. Methods: We performed a historical matched case-control study: participants were adults >18 years old presenting to two tertiary care emergency departments (ED) or one regional cardiac referral center. Cases: new ED or in-hospital diagnosis of non-traumatic AAS confirmed by computed tomography or echocardiography. Controls: triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 4:1 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2. Results: Data were collected from 2002-2014 yielding 194 cases of AAS and 776 controls (mean age of 65(SD 14.1) and 66.7% male). Of the 194 cases of AAS, 32 (16.5%) were missed on initial assessment. Chest pain unspecified (20.7%), abdominal pain unspecified (9.9%) and acute coronary syndrome (8.7%) were the top diagnoses in the control population. Absence of acute onset pain (Sensitivity 95.9% negative likelihood ratio (LR-) 0.07(0.03-0.14)), and a negative D-dimer (Sensitivity 96.7%, LR- 0.05(0.01-0.18)) can help rule out AAS. Presence of tearing/ripping pain (Specificity 99.7%, LR+42.1 (9.9-177.5), a history of aortic aneurysm (Specificity 97.8%, LR+6.35(3.54-11.42)), hypotension (Specificity 98.7%, LR+ 17.2(8.8-33.6)), pulse deficit (Specificity 99.3, LR+31.1(11.2-86.6)), neurological deficits (Specificity 96.9%, LR+ 5.26(2.9-9.3)), and a new murmur (Specificity 97.8%, LR+ 9.4(5.5-16.2) ) can help rule in the diagnosis of AAS. Conclusion: Patients with one or more high-risk feature should be considered high risk, whereas patients with no high risk and multiple low risk features are at low risk for AAS. Further research should focus on a combination of these factors to guide who warrants further investigation thus reducing miss rate, morbidity and mortality.