bluuebunny/crossref_metadata_2025 huggingface dataset:
On the relation between the extended supporting hyperplane algorithm and Kelley’s cutting plane algorithm
Authors: Serrano Felipe , Schwarz Robert , Gleixner Ambros
Published: May 2020

Recently, Kronqvist et al. (J Global Optim 64(2):249–272, 2016) rediscovered the supporting hyperplane algorithm of Veinott (Oper Res 15(1):147–152, 1967) and demonstrated its computational benefits for solving convex mixed integer nonlinear programs. In this paper we derive the algorithm from a geometric point of view. This enables us to show that the supporting hyperplane algorithm is equivalent to Kelley’s cutting plane algorithm (J Soc Ind Appl Math 8(4):703–712, 1960) applied to a particular reformulation of the problem. As a result, we extend the applicability of the supporting hyperplane algorithm to convex problems represented by a class of general, not necessarily convex nor differentiable, functions.
Evaluation of thermal properties of MMCp composites with silver alloy matrix
Authors: Wieczorek Jakub , Maciąg Tomasz , Kowalczyk Karolina , Migas Damian
Published: May 2020

Silver, silver alloys, and composites with silver matrix are used mainly as electric contacts, circuit-breakers, and slide bearings. Contacts working conditions require as high as possible thermal and electrical conductivity, wear resistance during electric arc work, low susceptibility to tacking, and chemical stability. Unreinforced silver alloys do not meet those expectations, hence increasing interest in metal matrix composites. Reinforcing with ceramic particles improves tribological wear resistance and minimizes formability of silver alloys. At the same time, introduction of ceramic particles decreases thermal and electrical conductivity. In this paper, manufacturing method of silver-based composites reinforced with particles Al2O3, SiC, and glassy carbon was described. Composites were subjected to differential thermal analysis. Furthermore, thermal diffusivity measurements using laser flash method, as well as measurements of linear thermal expansion coefficient using dilatometric method were performed in order to determine heat conductivity of the prepared composites.
Climbing up ladders and sliding down snakes: an empirical assessment of the effect of social mobility on subjective wellbeing
Authors: Dolan Paul , Lordan Grace
Published: May 2020

We examine how intergenerational mobility impacts on subjective wellbeing (SWB) drawing on data from the British Cohort Study. Our SWB measures encapsulate both life satisfaction and mental health, and we consider both relative and absolute movements in income. We find that relative income mobility is a significant predictor of life satisfaction and mental health, whether people move upward or downward. For absolute income, mobility is only a consistent predictor of SWB and mental health outcomes if the person moves downwards, and in this case the impact is far larger than relative mobility. For both relative and income mobility, downward movements impact SWB to a greater extent than upward movements, consistent with exhibiting loss aversion. Notably, we find that social class mobility does not affect SWB. We present evidence that the significant relative and absolute mobility effects we find operate partially through financial perceptions and consumption changes which can occur because of income mobility.
COVID-19: is fibrosis the killer?
Authors: Leask Andrew
Published: May 2020

COVID-19 is a respiratory disease. A recent report in Lancet examined, retrospectively, 137 patients with COVD-19. Patients that died had elevated IL-6 levels and acute respiratory distress syndrome. These data have obvious implications for how to control mortality in COVID-19.
Organic barley producers’ desired qualities for crop improvement
Authors: Baker Brian P. , Meints Brigid M. , Hayes Patrick M.
Published: May 2020

Barley fits well into many different organic farming systems. It can be grown as either a winter or spring annual crop in many temperate regions. Barley can be used for food, malting, or animal feed, providing growers with diverse marketing opportunities. Despite its advantages, many organic farmers in the USA have not adopted barley as a regular crop in their rotation. Researchers surveyed organic barley producers to discover what they considered to be the main obstacles to growing barley. The primary obstacles identified were limited markets and price. Breeding and development of high-quality barley suitable for organic systems and specialty markets may be a way to expand markets and secure a better price. Farmers identified yield as the most important agronomic trait of interest, but other traits such as nutritional quality were also highly ranked. Naked (hull-less) barley bred for multi-use quality is a possible alternative that allows organic farmers to sell into multiple markets. Most respondents expressed interest in the development of such varieties suitable for organic farming conditions. The researchers conducted follow-up interviews to obtain detailed information on how barley is used in organic farming systems, production practices, costs of production, and what traits farmers would like to see breeders focus on.
Meta-supervision for Attention Using Counterfactual Estimation
Authors: Choi Seungtaek , Park Haeju , Hwang Seung-won
Published: May 2020

Neural attention mechanism has been used as a form of explanation for model behavior. Users can either passively consume explanation or actively disagree with explanation and then supervise attention into more proper values (attention supervision). Though attention supervision was shown to be effective in some tasks, we find the existing attention supervision is biased, for which we propose to augment counterfactual observations to debias and contribute to accuracy gains. To this end, we propose a counterfactual method to estimate such missing observations and debias the existing supervisions. We validate the effectiveness of our counterfactual supervision on widely adopted image benchmark datasets: CUFED and PEC.
Coffee extracts effectively inhibit the formation of α-chymotrypsin amyloid-like fibrils in aqueous ethanol in vitro
Authors: Kotormán Márta , Bedő Vanda Andrea
Published: May 2020

In this study, an in vitro α-chymotrypsin aggregation model was used to demonstrate that certain extracts of commercial coffees effectively inhibit protein aggregation in 55% ethanol at pH 7.0. To detect the anti-amyloidogenic effect of the various coffee extracts, turbidity measurements and Congo red binding assays were performed as well as the determination of the total polyphenol content of the extracts. The greatest fibril formation inhibitory effect was exerted by the Eduscho coffee extract, which contained also the most of the phenolic compounds. The Eduscho coffee extract inhibited the fibrillation of the α-chymotrypsin dose dependently. Coffee extracts are effective anti-aggregation agents, and their beneficial effects strongly correlate with the total phenolic content.
The vascular flora of Pécs and its immediate vicinity (South Hungary) I.: species richness and the distribution of native and alien plants
Authors: Wirth Tamás , Kovács Dániel , Sebe Krisztina , Csiky János
Published: May 2020

Urbanization is one of the major causes of species loss and the homogenization of the world's flora. Our coarse-scale floristic mapping project of the largest south Transdanubian city, Pécs, is the first grid-based urban study in Hungary that reveals the current pattern of the vascular flora. Beyond the general description of the project, the species richness, the number of native, archaeophyte, neophyte and legally protected taxa are presented in the scale of the grid units (2.2 km2) and according to the residential area of the city. Relationships between the number and proportion of natives, archaeophytes, neophytes, protected species versus the proportion of built-up areas, forest coverage and elevation are estimated by linear regression models. Among the 1458 spontaneous or subspontaneous vascular plant species of the study area 131 are legally protected. The average number of species per grid unit is 338. Regression models show that the number of aliens decreases with forest coverage and increases with the rate of built-up areas, while number of natives shows opposite trends as a function of the same variables. These opposite trends lead to the conclusion that in the case of the vascular flora of Pécs the “poor get richer” theory is supported. Among the most frequent species hemicryptophytes, widespread, native and zoochorous plants are dominant. The most widespread four invasive taxa are native to North America.
LO80: Perfecting practice for rare procedures: a simulation-based, multi-centre randomized trial
Authors: Petrosoniak A. , Hicks C. , Gray S. , McGowan M. , Sherbino J. , Monteiro S.
Published: May 2020

Introduction: Mastery learning, which deconstructs a complex task into sequential sub-steps combined with deliberate practice to achieve each step in sequence, represents an important method to enhance simulation-based procedural skills training. However, the evidence to support the effectiveness of this theory to improve learning is lacking. This study compared mastery learning using deliberate practice with self-guided practice on skill performance of a rarely performed, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). Methods: In this multi-centre, randomized study at five North American emergency medicine (EM) residency training programs, we assigned 166 EM postgraduate trainees to either mastery learning and deliberate practice (ML + DP) or self-guided practice for BAC. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test) and after (post-test) each training session. The primary outcome was post-test skill performance using a 5-point global rating score (GRS). A secondary outcome, defined a priori, was performance time to complete the BAC skill (chronometry). Results: There was no significant difference in post-test BAC performance after ML + DP or self-guided practice. Performance scores improved for both groups by 13% from the pre-test to post-test (F (1,138) = 43, p < 0.001). Overall, time to complete the BAC improved significantly from pre-test (87.6 seconds) to posttest (54.1 seconds), (F, 1,149) = 122, p < 0.001). At post-test, the ML + DP group performed the skill 7.4 seconds faster than the self-guided practice group (F (1,150) = 6.77, p < 0.01). Conclusion: Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource intensive and its efficacy is not fully defined. In this study, MP + DP did not result in improved global performance; it did result in faster performance times, a relevant finding for time-sensitive procedures. These results are important for educators who seek to optimize technical skills training in a competency-based model of medical education. Our findings suggest that time-sensitive procedures might benefit from ML + DP teaching strategies to enhance time to procedural performance.
MP09: Predictors of return acute asthma visits among patients receiving guideline recommended discharge management in the emergency department
Authors: Dhaliwal C. , Haji T. , Leung G. , Madhura T. , Giangioppo S. , Radhakrishnan D.
Published: May 2020

Introduction: Despite improvements in the recognition of asthma among the pediatric population and the use of preventative therapies, rates of emergency department (ED) visits and hospitalizations remain high, leading one to question how these acute health care visits for asthma can be further avoided. In this study, we aimed to identify predictors of future repeat acute care visits among children and adolescents who had already received ‘best practice’ discharge treatments and instructions during their first asthma ED visit. Methods: We performed a retrospective single center cohort study of all children ages 1-17 years presenting to the ED at the Children's Hospital of Eastern Ontario in Ottawa, Canada for an acute asthma exacerbation during a 1-year time frame between September 1, 2014 – August 31, 2015. Only children with no prior ED asthma visit and documentation of receipt of a prescription for inhaled corticosteroids and/or a written asthma action plan were included. Multivariable logistic regression was performed to identify predictors of repeat future asthma ED visit or hospitalization in the year following the first ED visit. Results: We identified 909 children with an eligible ED visit during the study period, of whom 24% had a repeat asthma ED visit or hospitalization within the subsequent 1 year. Predictors of repeat acute asthma visits included having a nut allergy (OR 1.76, 95% CI: 1.15, 2.70), higher severity symptoms at triage (OR 2.04, 95% CI: 1.23, 3.39), a primary care physician (OR 2.23, 95% CI: 1.26, 3.93), or a prior history of asthma (OR 1.53, 95% CI: 1.03, 2.28). Conclusion: In children and adolescents with repeat asthma ED visits and hospitalizations despite having received ‘best practice’ asthma discharge management at their first ED visit, factors such as having an allergy to nuts, higher severity symptoms at presentation, a prior history of asthma, and having a primary care provider may be used to identify these more high-risk children and adolescents. Such parameters can be used practically to target and apply more intensive preventative interventions to those most in need at the first ED visit, in order to prevent future return visits.
MP27: Using a massive online needs assessment to guide the evolution of the EM Sim Cases website
Authors: Dinh A. , Baylis J. , Thoma B. , Chaplin T. , Petrosoniak A. , Caners K. , Hall A. , Heyd C. , Chan T.
Published: May 2020

Innovation Concept: EM Sim Cases is an innovative, open-access website that was created in 2015 to publish medical simulation resources including standardized, peer-reviewed simulation cases. Herein we describe our interim analysis. Methods: We performed a massive online needs assessment using a methodology previously described by Chan et. al. to determine how we can shape EM Sim Cases to meet the needs of learners and educators who use it. We engaged with simulation experts from the Emergency Medicine Simulation Education Research Collaborative to design a Google Forms survey using best practices in survey design. We distributed the survey to our target community of practice via Twitter, email, and a blog post published on emsimcases.com. Curriculum, Tool, or Material: We received 81 responses from simulation educators representing 8 medical specialties and 13 countries. Most survey respondents identified themselves as staff physicians (n = 44) and specialized in emergency medicine (n = 39). They had 0-21+ years of experience. 37% of respondents (n = 30) stated that material from EM Sim Cases makes up 25% or more of their simulation curriculum. Several respondents noted that using this content made them feel more confident and more current. Respondents praised EM Sim Cases for a well-organized case format, the proper level of detail, consistency between case designs, and the wide variety of cases. Suggested improvements included an opportunity to directly comment on cases and more cases in pediatric, rural, and advanced airway management situations. Suggestions were made to improve the navigability of the website. Respondents wanted to see additional blog content on debriefing strategies and self-made task/skill trainers. Conclusion: EM Sim Cases is a novel, free open-access simulation resource. Using a massive online needs assessment we were able to determine future directions including case topics, website reorganization, and educational material. We were also able to capture how impactful a resource like this can be to clinical and educational practice outside of the simulation setting.
MP30: Reducing unnecessary oral contrast in patients undergoing enhanced abdomen/pelvis computed tomography in the emergency department: A multicentre project
Authors: Dowling S. , Johal H. , Morris R. , Nobbee D. , Wang D. , Lang E.
Published: May 2020

Background: Traditionally, radiologists have routinely recommended oral contrast agents (such as Telebrix®) for patients undergoing a computed tomography of the abdomen/pelvis (CTAP), but recent evidence has shown limited diagnostic benefits for most emergency department (ED) patients. Additionally, the use of oral contrast has numerous drawbacks, including patient nausea/vomiting, risk of aspiration and delays to CTAP completion and increased ED length of stay (LOS). Aim Statement: The aim was to safely reduce the number of ED patients receiving oral contrast prior to undergoing CTAP and thereby reduce ED length of stay. Measures & Design: An evidence-based ED protocol was developed in collaboration with radiology. PDSA cycle #1 was implementation at a pilot site to identify potential barriers. Challenges identified included the need to change the electronic order sets to reflect the new protocol, improved communication with frontline providers and addition of an online BMI calculator. PDSA cycle #2 was widespread implementation across all 4 ED's in the Calgary zone. The protocol was incorporated into all relevant electronic ED order sets to act as a physician prompt. Using administrative data, we extracted and analyzed data using descriptive and inferential statistics for the outcomes and balancing measures from a period of 12 months pre- and 12 months post-intervention. Evaluation/Results: A total of 14,868 and 17,995 CTAP exams were included in the pre and post periods, respectively. There was a reduction in usage of oral contrast from 71% to 30% (P < 0.0001) in the pre- and post-study period, respectively. This corresponded to a reduction in average time of CT requisition to CT report completed from 3.30 hours to 2.31 hours (-0.99 hrs, P = 0.001) and a reduction in average ED LOS from 11.01 hours to 9.92 hours (-1.08 hrs, P < 0.0001). The protocol resulted in a reduction of 19,434.6 patient hrs in the ED. Run charts demonstrate change was sustained over time. Our protocol did not demonstrate an increase in rates of repeat CTAP (P = 0.563) at 30 days, nor an increase in patient re-admission within 7 days (P = 0.295). Discussion/Impact: Successful implementation of an ED and radiology developed protocol significantly reduced the use of oral contrast in patients requiring enhanced CTAP as part of their diagnostic work up and, thereby, reduced overall ED LOS without increasing the need for repeat examinations within 30 days or re-admission within 7 days.
MP40: What are the factors contributing to medico-legal risk of procedural interventions performed by physicians practicing emergency medicine?
Authors: Lemay K. , Finestone P. , Liu R. , Gorter R. De , Calder L.
Published: May 2020

Introduction: Physicians who practice emergency medicine (EM) often perform procedural interventions, which can occasionally result in unintended patient harm. Our study's objective was to identify and describe the interventions and contributing factors associated with medico-legal (ML) cases involving emergency physicians performing procedural interventions. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, ML organization which represented over 99,000 physicians at the time of this study. We extracted five years (2014-2018) of CMPA data describing closed ML cases involving procedural interventions (e.g. suturing, reducing a dislocated joint) and excluding interventions related to pharmacotherapy (e.g. injection of local anesthetic), diagnosis (electrocardiograms) and physical assessments (e.g. ear exams), performed by physicians practicing EM. We then applied an internal contributing factor framework to identify themes. We analysed the data using descriptive statistics. Results: We identified 145 cases describing 145 patients who had 205 procedures performed in the course of their EM care. The three most common interventions were orthopedic injury management (47/145, 32.4%), wound management (43/145, 29.7%), and Advanced Cardiac Life Support (24/145, 16.6%). Out of 145 patients, 93.8% (136/145) experienced a patient safety event, and 55.9% (76/136) suffered an avoidable harmful incident. One quarter of patients suffered mild harm (34/76, 25.0%), 18.4% of patients died, 14.5% suffered severe harm, and 13.2% moderate harm. Peer experts were critical of 86/145 cases (59.3%) where the following provider contributing factors were found: a lack of situational awareness (20/68, 29.4%), and deficient physician clinical decision-making (54/68, 79.7%). Clinical decision-making issues included a lack of thoroughness of assessment (33/54, 61.1%), failure to perform tests or interventions (21/54, 38.9%), and a delay or failure to seek help from another physician (17/54, 31.2%). Peer experts were also critical of 48.8% of cases containing team factors (42/86) due to deficient medical record keeping (26/42, 61.9%), and communication breakdown with patients or other team members (25/42, 59.5%). Conclusion: Both provider and team factors contributed to ML cases involving EM physicians performing procedural interventions. Addressing these factors may improve patient safety and reduce ML risk for physicians.
MP44: Implementing rural advanced care community paramedics in rural and remote British Columbia: a qualitative research approach
Authors: Besserer F. , Banner-Lukaris D. , Tallon J. , Kandola D.
Published: May 2020

Introduction: Community paramedicine is well-established with an increasing evidence base to support its role in improving healthcare delivery in Canada and across the world. In British Columbia (BC), the BC Emergency Health Services (BCEHS) community paramedicine program provides an avenue to expand the Advanced Care Paramedic (ACP) role in underserved rural and remote communities across the province. Methods: We undertook stakeholder consultations using purposive sampling to better understand the barriers and facilitators impacting the integration of rural advanced care community paramedics (RACCPs) in 6 BC communities and to evaluate stakeholder perspectives of the implementation and impacts of the RACCP. 18 in-depth interviews were completed with a diverse range of stakeholders. The interviews were analyzed using a qualitative descriptive approach and the Theoretical Domains Framework. Results: A number of key facilitators and barriers to implementation of the RACCP were identified. Facilitators included the RACCP bridging significant gaps in existing community-based healthcare services including palliative care, harm reduction, and home-based assessment. The RACCP also provides leadership within their communities by actively engaging in the delivery of informal and formal debriefing, mentorship, and education. Identified barriers to RACCP implementation included confusion over the scope of the RACCP role, lack of shared health data, and various regulatory challenges. Several priority areas for ongoing development were also identified including workforce planning, addressing regulatory requirements, developing a strategic and systematic activation and dispatch process, providing continuing mentorship and supports for RACCPs, and the importance for ongoing engagement with end-users to determine the impact of the RACCP role for community health services. Conclusion: This research provides a strong foundation for addressing healthcare delivery in rural and remote BC by identifying the unique challenges communities face in healthcare provision and is a leading initiative for the ongoing development of professional paramedic practice across the province.
P007: Cunningham reduction of anterior shoulder dislocation facilitated by inhaled low-dose methoxyflurane – a pilot study
Authors: Wiemer H. , Campbell S. , Fitzpatrick R. , Carriere C. , Teed S. , Hico P. , Snook A. , Gallant J. , Belliveau J. , DeMone C.
Published: May 2020

Introduction: The Cunningham reduction method for anterior shoulder dislocation offers an atraumatic alternative to traditional reduction techniques without the inconvenience and risk of procedural sedation and analgesia (PSA). Unfortunately, success rates as low as 27% have limited widespread use of this method. Inhaled methoxyflurane (I-MEOF) offers a rapidly administered, minimally invasive option for short-term analgesia. We conducted a pilot study to evaluate the feasibility of studying whether I-MEOF increased success rates for atraumatic reduction of anterior shoulder dislocation. Methods: A convenience sample of 20 patients with uncomplicated anterior shoulder dislocations were offered the Cunningham reduction method supported by methoxyflurane analgesia under the guidance of an advanced care paramedic. Operators were instructed to limit their attempt to the Cunningham method. Outcomes included success rate without the requirement for PSA, time to discharge, and operator and patient satisfaction with the procedure. Results: 20 patients received I-MEOF and an attempt at Cunningham reduction. 80% of patients were male, median age was 38.6 (range 18-71), and 55% were first dislocations of that joint. 35% (8/20 patients) had reduction successfully achieved by the Cunningham method under I-MEOF analgesia. The remainder proceeded to closed reduction under PSA. All patients had eventual successful reduction in the ED. 60% of operators reported good to excellent satisfaction with the process, with inadequate muscle relaxation being identified as the primary cause of failed initial attempts. 80% of patients reported good to excellent satisfaction. Conclusion: Success with the Cunningham technique was marginally increased with the use of I-MEOF, although 65% of patients still required PSA to facilitate reduction. The process was generally met with satisfaction by both providers and patients, suggesting that early administration of analgesia is appreciated. Moreover, one-third of patients had reduction achieved atraumatically without need for further intervention. A larger, randomized study may identify patient characteristics which make this reduction method more likely to be successful.
P011: A learning module for better medical record review research.
Authors: Vinken J. , Upadhye S.
Published: May 2020

Innovation Concept: The objective of this research study was to create a flipped classroom, interactive, experiential learning module on how to do a medical record review study. It is designed for medical students, residents, physicians, and researchers to have a remote, online, but interactive experience that expands on textbook concepts. The “flipped classroom” means that learners will guide their own education. This learning module will include a pre-test, interactive video module, and a post-test. These components will ensure each learner reaches previously set learning goals and not only solidify the learning of learners but validate the educational method, proving its value. Methods: A review of the literature indicates that medical record review is a valuable method of research in emergency medicine however researchers may encounter methodological difficulties, and sometimes medical record reviews are performed in a suboptimal manner due to these difficulties. We are creating a learning module that builds off of the chapter in the Royal College Research Guide and elaborates on various elements, including sample size calculation. Previous work indicates that a flipped classroom approach in medicine to learning has been well developed and is backed by evidence as well as learner preference to guide their own learning. Curriculum, Tool, or Material: The learning module was initiated from the Royal College Research Guide chapter on how to conduct medical record review research. The module is a white board drawing style video that combines elements of explanation and elaboration of the chapter information and a step by step, learner-interactive example of a medical record research project creation. Conclusion: Medical record review research is accessible to many researchers due to the availability of data. This innovation would help ensure that with this availability, good research is being conducted. Future steps will involve testing and validating this learning module using the pre and post-tests, and expanding to create other, similar modules for other Royal College Research Guide chapters.
P039: Utilization of serum D-dimer assays and computed tomography pulmonary angiography (CTPA) scans in the diagnosis of pulmonary embolism among emergency department (ED) physicians
Authors: Salehi L. , Phalpher P. , Yu H. , Ossip M. , Valani R. , Mercuri M.
Published: May 2020

Introduction: As the availability of Computed Tomography Pulmonary Angiography (CTPA) to rule out pulmonary embolism (PE) increases, so too does its utilization, and consequent overutilization. A variety of evidence-based algorithms and decision rules using clinical criteria and D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a PE in low-risk patients. However, studies have shown mixed results with respect to both physician uptake of these decision rules and their impact on improving ordering practices among physicians. The objective of this study is to describe the prevalence of D-Dimer utilization among ED physicians and its impact on positive yield rates of CTPAs in a community setting. Methods: Data was collected on all CTPA studies ordered by ED physicians at two very high-volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. For each CTPA, we determined if 1) a D-Dimer had been ordered prior to CTPA, if 2) the D-Dimer was positive, and if 3) the CTPA was positive for a PE. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Results: A total of 2,811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer. Of those 1,847 patients who underwent D-Dimer testing prior to the CTPA, 343 (18.7%) underwent a CTPA despite a negative D-Dimer. When compared as a group, those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those CTPAs ordered without a prior D-Dimer (9.9% versus 11.3%, p = 0.26). Conclusion: The findings of this study present a complicated picture of the impact of D-Dimer utilization on CTPA ordering patterns. There is evidence of suboptimal uptake of routine D-Dimer ordering, and adherence to guidelines in terms of forgoing CTPAs in low-risk patients with negative D-Dimers. While this study design leaves unanswered the question of how many CTPAs were avoided as a result of a negative D-Dimer, the finding of a similar positive yield among those patients who had a D-Dimer ordered versus those who did not is interesting, and illustrative of the issues arising from the high false-positive rates associated with D-Dimer screening.
P051: A chart review of emergency department visits following implementation of the Cannabis Act in Canada
Authors: O'Brien M. , Rogers P. , Smith E.
Published: May 2020

Introduction: The legalization of cannabis for recreational use in 2018 remains a controversial topic. There are multiple perceived benefits of cannabis including pain relief, treatment of epilepsy syndromes, and improving body weight of cancer patients. However, there are also many potential risks. The short-term health consequences include cannabinoid hyperemesis syndrome and cannabis induced psychosis. These conditions directly impact the influx of patients presenting to Emergency Departments (ED). There is currently limited research in the area of cannabis legalization burden. However, the studies performed have shown a significant impact in those states which cannabis is legal. A study completed in Colorado found that hospitalization rates with marijuana related billing codes increased from 274 to 593 per 100 000 hospitalizations after the state legalization of recreational cannabis. This study aims to examine if Canada's hospitals are experiencing the same burden as other jurisdictions. Methods: A descriptive study was preformed via a retrospective chart review of cannabis related visits in tertiary EDs in St. John's, NL, from six months prior to the date of legalization of cannabis for recreational use, to six months after. Hospital ED visit records from both the Health Science Centre and St. Clare's Mercy Hospital were searched using keywords to identify patients who presented with symptoms related to cannabis use. We manually reviewed all visit records that included one or more of these terms to distinguish true positives from false positive cases, unrelated to cannabis use. Results: A total of 287 charts were included in the study; 123 visits were related to cannabis use six months prior to legalization, and 164 six months after legalization. A significant increase in ED visits following the legalization of recreational cannabis was seen (p < .001). There was no significant difference in the age of users between the two groups. Additionally, the number one presenting complaint due to cannabis use was vomiting (47.7%), followed by anxiety (12.2%). Conclusion: Following the implementation of the Cannabis Act in Canada, EDs in St. John's, NL had a statistically significant increase in the number of visits related to cannabis use. It is important to determine such consequences to ensure hospitals and public health agencies are prepared to treat the influx of visits and are better equipped to manage the associated symptoms.
P081: The summer of the e-scooter: a multicenter evaluation of the emergency department impact of rentable motorized scooters in Calgary
Authors: Islam A. , Koger K. , VandenBerg S. , Wang D. , Lang E.
Published: May 2020

Introduction: Calgary's introduction of rentable electronic scooters (e-scooters) in July of 2019 was met with wild popularity, representing the third most popular launch after Tel-Aviv and Paris. The present study aims to characterize the injury burden seen in all Calgary Emergency Departments (EDs) and Urgent Care Centres (UCCs) attributable to e-scooters since their 2019 introduction. Methods: We retrospectively reviewed all electronic medical records of patients presenting to Calgary EDs or UCCs with the term “scooter” in the triage note, where exclusion criteria are considered for non e-scooter injuries (e.g: non-motorized scooters). Trends in scooter injuries will be compared between April - October 2018 (control arm preceding e-scooter introduction) and April - October 2019. Injury incidence, types, patient demographics, and relative risk compared to bicycle-related injuries will be determined. Descriptive statistics will be calculated. Moreover, 33 ED visits were brought in by EMS and provide information about injury types and locations of injuries involving EMS transport. Results: Preliminary data reveals 540 scooter-related visits (3.10% admitted/transferred) between July 8th and September 30th 2019 (mean age of 28, 56.30% male). Conversely, the number of bicycle-related visits and motor vehicle related injuries were 1482 and 586 (9.90% and 9.70% admitted/transferred) respectively over the same time period suggesting a greater burden but likely a lower per-ride incidence of injury requiring ED or UCC care. Moreover, between July 8th to October 1st 2019, 33 e-scooter presentations involved EMS (21.21% admitted to hospital), where 12.12% involved upper extremity injury, 21.21% were lower extremity injuries, and 6.06% were head injuries (mean age of 34, 48.48% male). Conversely, estimated EMS transfers to EDs or UCCs for bicycle injuries and motor vehicle injuries were 197 and 463 respectively over the same time period. ICU admissions or fatality were not recorded. Conclusion: Representing the most comprehensive study of e-scooter injury patterns in Canada to date, we here demonstrate a significant injury burden attributable to e-scooters following their introduction in Calgary in 2019. Bicycle-related and motor vehicle injuries were both more prevalent in this time period, and required more EMS visits. Further characterization of injury types, injuries and comparison with injury patterns prior to e-scooter introduction is yet to be determined.
P100: Une activité de simulation de table à des fins de formation interprofessionnelle pour enseigner une nouvelle procédure intrahospitalière de code rose : une étude pilote exploratoire et rétrospective sur la perception des apprenants
Authors: Frégeau A. , Cournoyer A. , Soucy N. , Fortier D. , Desaulniers P. , Castonguay V. , Fleet R.
Published: May 2020

Introduction: Les erreurs médicales sont causées par des failles de système plutôt qu'un seul individu. Dans ce contexte, de multiples designs pédagogiques de formation interprofessionnelle (FIP) ont été proposés pour développer une meilleure collaboration interprofessionnelle. L'une des initiatives pédagogiques proposées en médecine de désastre est la simulation de table (TTX). La TTX consiste à simuler une situation de code orange dans un environnement informel où les participants doivent discuter de la suite logique des actions à prendre. Le protocole d'arrêt cardiaque intra-hospitalier chez le nourrisson de moins de 30 jours (code rose) ayant été mis à jour au Centre hospitalier de l'Université de Montréal (CHUM), cela a généré un besoin de FIP au sein des équipes. Ainsi, nous avons développé une FIP innovante en utilisant la TTX pour enseigner un nouveau protocole de code rose. L'objectif primaire de la présente étude est d'évaluer la perception des apprenants à propos de cette FIP. Methods: La présente étude rétrospective de cohorte s'est déroulée en mars 2019 au centre de simulation du Centre hospitalier de l'Université de Montréal. Un groupe interprofessionnel (médecins, infirmières, inhalothérapeutes, préposés aux bénéficiaires, etc.) a été recruté. Un sondage de satisfaction des participants leur a été remis immédiatement après la TTX. Des statistiques descriptives (n, %) ont été réalisées. Les commentaires recueillis lors du débreffage ont permis de nuancer les résultats et d'apporter des changements à la nouvelle procédure de code rose. Results: Un total de 13 participants ont participé à la TTX, dont 10 ont répondu au sondage (10/13 : 77%). 3 observateurs ont participé à la TTX et ont tous répondu à certaines questions du sondage (3/3 : 100%). Suite à la TTX, 80% (n = 8) des participants ont eu l'impression de mieux comprendre leur propre rôle et 90% (n = 9) des participants ont eu l'impression de mieux comprendre le rôle des autres professionnels. Tous (100%, n = 13) ont apprécié la TTX et ont affirmé qu'il était probable ou très probable qu'ils participent à nouveau à une telle activité de FIP s'ils y étaient invités et qu'ils recommanderaient à un collègue d'y participer. Conclusion: Il est possible de réaliser une TTX pour une autre procédure d'urgence que le code orange, c'est-à-dire pour le code rose et cela est apprécié des participants. Ces derniers se sont sentis plus confiants dans leur rôle et dans leur connaissance du rôle des autres professionnels.
P104: What are the current practices and barriers to screening for suicidal thoughts in Canadian emergency departments?
Authors: Fernandes J. , Chakraborty A. , Scheuermeyer F. , Barbic S. , Barbic D.
Published: May 2020

Introduction: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) current practices and barriers to screening for suicidal thoughts (ST). Methods: We developed a web-based survey on suicide knowledge, which was pilot tested by two emergency physicians and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. Results: 193 EPs responded to the survey (response rate 16%), with 42% of EPs practicing in Ontario. 35% of EPs were female, the mean age was 48 (95% CI 47.3-48.7), and mean years in practice was 17 (95% CI 16.3-17.7). Academic practice location was reported by 55% of EPs, and 81% reported access to an inpatient psychiatry service. 142 EPs (82%) reported no protocol for screening for ST in their ED. Of EPs reporting an existing protocol, the most common practice was routine screening at triage (43%). The most commonly identified screening tools were HEADS-ED (25%) and PHQ-9 (21%). 70% of EPs felt the ED was a good place for screening for ST, yet 66% identified slower clinical care as a potential barrier. A strong commitment to treatment and follow up was identified by 68% of EPs as a necessary requirement to implementing ST screening in their ED. A targeted 2-4 question screen was the preferred screening option for 62% of EPs responding. Conclusion: A majority of EPs report no protocol for screening for ST in their ED, yet identify the ED as a good place for screening efforts. Potential barriers to widespread ST screening in the ED include a strong commitment to patient treatment and follow up, and diminished clinical efficiency.
P112: Strengthening inter-professional collaboration in home-based community paramedic programs
Authors: Jagos K. , Drennan I. , McNamara M. , Limoges J.
Published: May 2020

Introduction: Community paramedic programs are being implemented to leverage existing resources and contribute to a sustainable patient-centered healthcare system. Expanding the role of paramedics into home care requires new collaborative relationships with healthcare providers such as nurses and physicians. Developing effective and productive collaborative relationships will enhance and support the integration of community paramedic programs. Our objective was to describe the barriers and facilitators to effective collaboration between nurses, physicians, and paramedics within home-based community paramedicine. Methods: We conducted semi-structured interviews with nurses, physicians, paramedics, and faculty who teach in paramedic programs. We explored the attitudes, perceptions, barriers, and enablers to collaboration in home-based community paramedic programs. Participants were recruited utilizing the professional networks of the researchers as well as snowball sampling. Recruitment in each group stopped when saturation was achieved. We conducted a thematic analysis of the interviews to generate findings related to our objectives. Results: We interviewed 33 participants with a typical cross-section of age, years of experience, and education. Overall, participants felt that collaboration was important for effective integration of community paramedics into home care and for ensuring a patient-centered approach to care. Currently, collaboration mostly occurs between physicians and paramedics and community paramedicine appears to be a siloed rather than integrated service. Few collaborative relationships exist between paramedics and nurses, despite the fact that nurses are highly involved in home care. We identified several barriers to effective collaboration including lack of understanding of the contributions of the different health providers, and regulatory and funding constraints. Inter-professional education that supports collaboration and facilitates dismantling of professional and service silos can support the effective integration of paramedics into home care. Conclusion: Strengthening networks of collaboration between nurses, physicians, and paramedics can help dismantle silos and enhance inter-professional collaboration to support appropriate integration of paramedics into home care. The willingness and positive attitudes for collaboration are assets that provide an excellent foundation upon which to move forward. Continuing education to support inter-professional collaboration is needed.
P121: A quality improvement project to improve medical imaging ordering workflow in the emergency department
Authors: Choi J. , Bhayana R. , Wang D. , Bartlett E. , Menezes R.
Published: May 2020

Background: Many computerized tomography (CT) scans ordered after-hours from the emergency department (ED) at our institution required a discussion between the emergency physician (EP) and radiology resident (RR), leading to workflow inefficiency. Aim Statement: The aim was to improve workflow efficiency and provider satisfaction, and reduce CT turnaround time, without significantly affecting CT utilization within six months. Measures & Design: We created a new workflow by creating an electronic list of ED CT requests that RRs monitor. RRs protocolled all requests and only called the ED physician for more details when required. The intervention was implemented in a stepwise fashion via plan-do-study-act cycles. An electronic survey measured qualitative outcomes, and quantitative outcomes were analyzed via statistical process control (SPC) charts and other statistical methods. Evaluation/Results: Survey response was high (76% EP, 79% RR). Most EPs and RRs felt more efficient (96.3%, 73.3%), RRs felt fewer disruptions (83.3%), and most EPs felt that scans were done faster (84.1%). We analyzed CT turnaround times and utilization using SPC charts and segmented regression analyses. Turnaround time trended to improvement (33 mins vs 29 mins on weekdays [WD], 37 mins vs 33 on weekends [WE]), but was not statistically significant. There was background rising CT utilization over time (+0.7 and + 1.9 CT/100 ED visits/year on WD and WE, respectively, p < 0.0005), but the intervention itself did not cause a significant change. The total number of pages to RR (a measure of workflow disruption) decreased significantly on the WDs (23 vs 19 pages, p = 0.0011), but not on WE (79 vs 75 pages, p = 0.1663). However when adjusting for number of scans ordered, there was a decrease in paging rates (0.73 vs 0.54 pages per scan ordered on WD [p < 0.00005], 3.24 vs 2.63 pages per scan ordered on WE [p = 0.0012]). Discussion/Impact: Our intervention led to improved work satisfaction and perceived efficiency experienced by both EPs and RRs. It did not statistically significantly affect imaging turnaround times or utilization rates. Our project shows that calling for preapproval of imaging studies does not seem to provide any benefit in our setting.