bluuebunny/crossref_metadata_2025 huggingface dataset:
LO92: Development of a predictive model for hospital admissions by utilizing frequencies of specific CEDIS presenting complaints
Authors: Lewis D. , Stoica G. , French J. P. , Atkinson P.
Published: May 2018

Introduction: With hospital occupancy rates frequently approaching 100%, even small variations in daily admission numbers can have a large impact. The ability to predict variance in emergency admission rates would provide administrators with a significant advantage in managing hospital daily bed requirements. There is a growing interest in patterns of hospital admissions, and many EDs utilize historical admission patterns to attempt to predict daily bed requirements. Previous studies have utilized patient demographics and past medical history to develop an admission likelihood model. We wished to examine the predictive strength of individual CEDIS presenting complaints (PC) on admission likelihood Methods: Using a database analysis of over 285,000 ED presentations (2013-2017), we calculated visit frequencies and admission rates by PC. Using a logistic regression analysis PCs were ordered from high to medium predictive strength. Results: Of 285,155 presentations, there were 38,090 hospital admissions, a rate of 13.36%. Based on the number of visit frequencies and admission rates, the PCs demonstrating high predictive strength were Direct Referral (effect=0.36, binomial CI: 0.28 to 0.44); Shortness of Breath (0.32: 0.26 to 0.41); General Weakness; Weakness/Query CVA; & Chest Pain Cardiac Features (each 0.30: 0.25 to 0.42); Altered level of consciousness (0.24: 0.16 to 0.31); and Confusion (0.18: 0.08 to 0.26). With our sample size, all remaining CEDIS PCs had low predictive value (the effect is <0.1), or were not predictive at all. Conclusion: We have demonstrated that, for our population, certain PCs are associated with an increased likelihood of admission and have quantified this effect using logistic regression analysis. Variance from the average daily admission rate may be predicted, in our population, by identifying these PCs at registration.We plan to develop a tool, based on this data and implemented at registration, to predict cumulative likely daily admission requirements as patients present over a 24hr period.
MP06: Predictors of hypothermia upon emergency department arrival in severe trauma patients transported to hospital via emergency medical services
Authors: Forristal C. , Van Aarsen K. , Columbus M. , Wei J. , Vogt K. , Mal S.
Published: May 2018

Introduction: Hypothermia in severe trauma patients can increase mortality by 25%. Active re-warming decreases mortality and is recommended in trauma management guidelines. Despite this, many emergency medical services (EMS) vehicles do not carry equipment for active re-warming. This study sought to determine the local rate of hypothermia in major trauma patients on trauma centre arrival (TCA), and to establish which patients are at highest risk by identifying factors present in the pre-hospital setting associated with hypothermia in a humid continental climate. Methods: This single-centre retrospective chart review included adults (age 18) in the local trauma registry (trauma team activation or injury severity score >12) from January 2009-June 2016. Patients were excluded if: temperature on TCA unknown or 38°C, not transported by EMS, or if there was >24 hrs from injury to TCA. The primary outcome was the rate of hypothermia (<35°C) in major trauma patients transported by EMS on arrival at the local trauma centre. Secondary outcomes included hospital length of stay and survival to discharge. Logistic regression was used to identify predictors of hypothermia on TCA; it included the following factors: age, sex, weight, number of comorbidities, injury severity, injury mechanism, EMS modality, direct transport from scene or referred from peripheral hospital, time on scene, transport time, local temperature, and pre-hospital heart rate, systolic blood pressure (SBP), intubation, and volume of crystalloid. Results: A total of 3070 adult traumas were included, 159 of which were hypothermic on TCA a rate of 5%. Multivariate analysis identified seven risk factors for hypothermia: intubation pre-hospital (OR 8.10, p<0.001), blunt trauma (OR 3.37, p=0.044 vs. penetrating, and OR 7.35, p=0.023 vs. other), direct transport (OR 1.94, p=0.005), number of comorbidities (OR 1.14, p=0.036), injury severity (OR 1.03, p<0.001), 1°C local temperature drop (OR 1.03, p<0.001), and 1mmHg SBP drop (OR 1.01, p<0.001). Ninety-four percent of normothermic patients and 69.2% of hypothermic patients survived to discharge. Average length of stay was 7.98 and 15.23 days respectively. Conclusion: Avoidance of hypothermia is imperative to the management of major trauma patients. Those at highest risk in a humid continental climate are severely injured blunt trauma patients with multiple co-morbidities, a low pre-hospital SBP and EMS intubation. Future studies should focus on the benefits of pre-hospital rewarming in these high-risk patients.
MP10: Implementation of the PulsePoint mobile device application in Kingston, Ontario, Canada: a pilot study on crowdsourcing bystander CPR for victims of out-of-hospital cardiac arrest
Authors: Ensan S. , O’Donnell L. , Brooks S. C.
Published: May 2018

Introduction: Every year 40,000 out-of-hospital cardiac arrests (OHCA) occur in Canada. Only 1 in 10 survive. Early bystander cardiopulmonary resuscitation (CPR) and defibrillation can triple odds of survival. PulsePoint is a mobile device application designed to crowdsource bystander CPR and public access defibrillation for victims of OHCA. Kingston, Ontario was the first Canadian city to launch PulsePoint. The objective of this project was to determine feasibility of PulsePoint implementation in a Canadian setting and to describe system performance. Methods: This was a descriptive observational study. We included all 9-1-1 incidents involving PulsePoint system activation in Kingston, Ontario and all confirmed, public location OHCAs assessed by local emergency medical services (EMS) between March 23, 2015 to January 23, 2017. By using time and location data from PulsePoint system alert notifications, we attempted to link each PulsePoint activation to de-identified ambulance call records. Results: Between March 23, 2015 to January 23, 2017, there were 258 PulsePoint system activations in Kingston and a total of 32 cases of confirmed OHCAs. Only 58 (22%) of PulsePoint activations could be linked to EMS records with high confidence. Of these linked cases, 10 were confirmed OHCAs, reflecting 17% (10/58) of all linked PulsePoint activations and 31% (10/32) of all confirmed OHCAs. Of the remaining 48 cases that triggered PulsePoint activation numerous final paramedic problem codes were assigned of which 14% (8/58) were deemed alcohol intoxication, 10% (6/58) were active seizures, 7% (4/58) were behavioural/psychiatric events, among others. 10 incidents (17%) that triggered PulsePoint activation did not have an assigned final paramedic problem code. Conclusion: Implementation of PulsePoint is feasible in Canadian communities. Improved capabilities for linking with local EMS data will improve data capture, program monitoring capacity, and opportunity for research. The impact of PulsePoint on clinical outcomes remains uncertain and should be determined in future research.
MP14: Community paramedic point of care blood analysis: validity and usability testing of two commercially available devices
Authors: Blanchard I. E. , Kozicky R. , Dalgarno D. , Goulder S. , Williamson T. , Biesbrook S. , Page L. , Leaman K. , Snozyk S. , Redman L. , Spackman K. , Doig C. , Lang E. , Lazarenko G.
Published: May 2018

Introduction: Community Paramedics (CPs) require access to timely blood analysis in the field to guide treatment and transport decisions. Point of care testing (POCT), as opposed to traditional laboratory analysis, may offer a solution, but limited research exists on CP POCT. The objective of this study is to compare the validity of two POCT devices (Abbott i-STAT® and Alere epoc®) and their use by CPs in the community. Methods: In a CP programme responding to 6,000 annual patient care events, a split sample validation of POCT against traditional laboratory analysis for seven analytes (sodium, potassium, chloride, creatinine, hemoglobin, hematocrit, and glucose) was conducted on a consecutive sample of patients. The difference of proportion of discrepant results between POCT and laboratory was compared using a two sample proportion test. Usability was analysed by survey of CP experience, an expert heuristic evaluation of devices, a review of device-logged errors, coded observations of POCT use during quality control testing, and a linear mixed effects model of Systems Usability Scale (SUS) adjusted for CP clinical and POCT experience. Results: Of 1,649 CP calls for service screened for enrollment, 174 had a blood draw, with 108 patient care encounters (62.1%) enrolled from 73 participants. Participants had a mean age of 58.7 years (SD16.3); 49% were female. In 4 of 646 (0.6%) individual comparisons, POCT reported a critical value that the laboratory did not; with no statistically significant difference in the number of discrepant critical values reported with epoc® compared to i-STAT®. There were no instances of the laboratory reporting a critical value when POCT did not. In 88 of 1,046 (8.4%) individual comparisons, the a priori defined acceptable difference between POCT and the laboratory was exceeded; occurring more often in epoc® (10.7%;95%CI:8.1%,13.3%) compared to i-STAT® (6.1%;95%CI:4.1%,8.2%)(p=0.007). Eighteen of 19 CP surveys were returned, with 11/18 (61.1%) preferring i-STAT® over epoc®. The i-STAT® had a higher mean SUS score (higher usability) compared to the epoc® (84.0/100 vs. 59.6/100; p=0.011). Fewer field blood analysis device-logged errors occurred in i-STAT® (7.8%;95%CI:2.9%,12.7%) compared to epoc® (15.5%;95%CI:9.3%,21.7%) although not statistically significant (p=0.063). Conclusion: CP programs can expect valid results from POCT. Usability assessment suggests a preference for i-STAT.
MP18: Development and implementation of a workshop for advanced care planning and goals of care conversations in the emergency department
Authors: Fletcher C. , Brisbois A. , Gauri A. , Ha D.
Published: May 2018

Introduction: Advanced care planning (ACP) and Goals of Care (GOC) discussions are becoming increasingly common in our emergency departments (ED). The national ACP task group has found that the majority of Canadians have not had prior ACP/GOC discussions, nor have they obtained proper documentation of their wishes. The task of having these difficult but important conversations falls frequently to the ED. Despite this, our emergency medicine (EM) residents receive little formal training in ACP discussions. To address this need, we developed and implemented a workshop in ACP/GOC conversations for the University of Alberta EM academic curriculum. Methods: A literature search was performed to identify best practices for ACP discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked to identify previous difficult ACP discussions and highlight aspects of these cases that were challenging in the ED environment. These experiences, best practices and published APC curricula informed the development of a 3-hour case-based workshop that was implemented in the 2016/17 academic year for EM staff and residents. Results: Cases utilized in the workshop emphasized common ACP/GOC situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC whose family did not accept the GOC designation. Case 2: A 72 year old with multiple comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with decreased LOC whose family asks for an ACP discussion in the ED. Participants were divided into groups (5-6 members). Each small group analyzed and discussed each case before the participants reconvened and discussed their opinions in one large group. ACP experts from palliative care, emergency medical services and EM facilitated the discussions highlighting the best practices from the literature for each case reviewed. Pre and post Likert surveys were distributed to workshop participants to assess changes in confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically significant improvement in learner confidence within the following areas (N=21; P<0.05): identifying patients appropriate for GOC discussions, initiating GOC discussions, and identifying barriers to GOC, in the ED. The majority (89%) of participants agreed the workshops should become part of our academic curriculum. Conclusion: An ACP/GOC workshop was successfully implemented and further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead, we will look at using other teaching modalities such as simulation to further enhance the delivery of the curriculum. We will also attempt to capture defined physician behaviors (e.g. documenting GOC in the ED chart, sending letters to family physicians documenting GOC discussions) to gauge uptake of the workshop principles into clinical practice.
MP27: Publishing emergency department wait times in the waiting room: implementation and evaluation of a co-designed patient centered solution
Authors: Calder-Sprackman S. , Klar E. , Rocker A. , Kwok E. S.H.
Published: May 2018

Introduction: Patients in our ED were dissatisfied with their waiting experience, which resulted in patient anxiety and complaints. In 8 months, we aimed to (1) improve patient satisfaction with the ED waiting experience from triage to physician initial assessment by a 15% improvement in patients who rate their experience very good/excellent on a Likert Scale, and (2) improve patient knowledge of ED wait time by a 50% increase in understanding on a Likert Scale. Methods: We co-designed a display with ED patients to notify those in the waiting room of their wait process and wait time. The intervention was selected after root cause diagnostics including: Fishbone exercise, Pareto Diagram, and Driver Diagram. The display was co-designed with ED patients and improved via PDSA cycles to establish information displayed and how to incorporate it into the waiting experience. After co-design, a low-fidelity display was piloted in the waiting room. Results: A family of measures were evaluated using patient/provider surveys and hospital data metrics. Outcome measures were (1) percentage of patients who rated their ED experience as very good/excellent on a Likert scale, and (2) patients who had a clear/very clear understanding of their wait time on a Likert scale. Process measures were the percentage of patients who (1) looked at the wait time display, and (2) felt they could communicate their wait time to others. Balancing measures were clerk/nurse satisfaction and self-reported interruptions of patients asking wait time. Outcomes were tracked using statistical process charts and run charts. Following display implementation, patient rating of their ED experience and patient understanding of wait time showed positive improvement. Clerks/nurses were also more satisfied with their jobs and self-reported interruptions decreased. Conclusion: A low-fidelity wait time display co-designed with patients improved patient satisfaction and understanding of ED wait times. We plan to develop an automated electronic display that resembles the low-fidelity display and evaluate the impact of the intervention on the established measures. This intervention has the potential to be sustainable, feasible for other EDs, and require minimal upkeep costs.
MP30: Impact des bicarbonates sur le devenir des patients souffrant dun arrêt cardiaque préhospitalier
Authors: Cournoyer A. , Notebaert E. , Cossette S. , Londei-Leduc L. , Chauny J. , Daoust R. , Morris J. , Iseppon M. , Lamarche Y. , Vadeboncoeur A. , Sokoloff C. , Piette E. , Larose D. , Champlain F. de , Paquet J. , Albert M. , Bernard F. , Denault A.
Published: May 2018

Introduction: Les patients souffrant dun arrêt cardiaque extra hospitalier (ACEH) sont fréquemment traités à laide de soins avancés en réanimation cardiovasculaire (SARC). Dans ce contexte, des bicarbonates de sodium sont parfois administrés à des patients en arrêt cardiaque réfractaire chez qui une acidose métabolique importante, une hyperkaliémie ou une intoxication est suspectée. Puisquil ny a que peu dévidences quant à cet usage, lobjectif de la présente étude est dévaluer lassociation entre le traitement à laide de bicarbonate de sodium (une dose ou plus) et le devenir (retour de circulation spontané et survie au congé) chez les patients souffrant dun ACEH. Methods: La présente étude de cohorte a été réalisée à partir des bases de données de la Corporation dUrgences-santé dans la région de Montréal entre 2010 et 2015. Les patients adultes ayant souffert dun ACEH dorigine médicale traités en préhospitalier par des paramédics de soins avancés prodiguant des SARC ont été inclus. Les associations dintérêt ont été évaluées initialement à laide de régressions logistiques univariées, puis à laide de régressions logistiques multivariées ajustant pour les variables sociodémographiques et cliniques pertinentes. Results: Un total de 1973 patients (1349 hommes et 683 femmes) dun âge moyen de 66 ans (±17) ont été inclus dans cette étude, parmi lesquels 77 (3,8%) ont reçu une dose de bicarbonate, 763 (37,5%) ont retrouvés un pouls en préhospitalier et 222 (10,9%) ont survécu jusquà leur congé de lhôpital. Sans ajustement, il y avait une association négative entre le traitement à laide de bicarbonates et le retour de circulation spontané (rapport de cotes [RC]=0,46 [intervalle de confiance {IC} 95% 0,27-0,79], p=0,005) et la survie au congé (RC=0,21 [IC 95% 0,05-0,86], p=0,030). Cependant, ces associations nétaient plus significatives suite à lajustement pour les autres covariables (RC ajusté=0,63 [IC 95% 0,34-1,18], p=0,15 et RC ajusté=1,69 [95% IC 0,29-10,01], p=0,56). Conclusion: Il ny a pas dassociation indépendante entre le traitement à laide de bicarbonates et le devenir chez les patients souffrant dun ACEH. Dans ce contexte, il serait adéquat de réaliser un essai clinique afin de trancher définitivement sur cette question.
MP32: Paramedics using near-infrared spectroscopy in out-of-hospital cardiac arrest: a feasibility study
Authors: Drennan I. , Gilgan J. , Goncharenko K. , Lin S.
Published: May 2018

Introduction: Long-term outcomes following out-of-hospital cardiac arrest (OHCA) remain poor. Two-thirds of OHCA patients surviving to hospital admission die from neurological injuries, and of those discharged, one-third have irreversible cognitive disabilities due to cerebral ischemia. Near-infrared spectroscopy (NIRS) is a non-invasive imaging technique which is able to continuously detect regional cerebral oxygenation (rSO2). NIRS monitoring has been used to measure rSO2 during in-hospital cardiac arrest resuscitation. Our study is the first feasibility study of paramedics applying NIRS monitoring during OHCA resuscitation. Methods: One NIRS monitor (Equanox 7600; Nonin, Plymouth, MI, USA) was placed on an Emergency Response Unit (ERU) with York Region Paramedic Services. ERU paramedics were trained to apply the device to patients foreheads during OHCA resuscitation and record rSO2 until arrival at hospital or termination of resuscitation. Paramedics did not alter any aspect of patient care by using the NIRS monitor. They were instructed to press an action marker on the device during ACLS interventions (e.g. defibrillation, intubation, medications, etc). rSO2 data was later downloaded for analysis. Our feasibility criteria was to obtain >70% of data files with rSO2 data and >70% of data files with event markers. Results: Data was collected from 24 OHCA patients over a period of 10 months. 19 cases (79%) files contained rSO2 data and 17 cases (71%) had event markers. The rSO2 data present in each file varied widely from complete recording for the entire call duration to sporadic brief readings. Event markers varied from 1 to 10 markers spaced throughout the cases. Conclusion: This is the first study to demonstrate that the use of NIRS by paramedics as part of OHCA resuscitation is feasible. Future studies are required to determine how rSO2 monitoring can be used to guide OHCA resuscitation. The results of this study will help inform protocols for future studies evaluating the use of NIRS in the out-of-hospital setting.
MP33: Refining nursing symptom-driven guidelines for ED laboratory test ordering
Authors: Campbell S. , Elnenaei M. , Nassar B. , Lou A. , Crocker B. , Connor N.
Published: May 2018

Introduction: Recent reports suggest that up to 30% of medical interventions provide no benefit to patients. In a response to ED over-crowding, guidelines commonly exist to guide blood test ordering in patients waiting to see a physician. In many cases, this increases the use of tests without benefiting patients. We describe a quality improvement project designed to reduce the number of laboratory tests considered routine for waiting patients. Methods: A multidisciplinary group reviewed existing symptom-prompted nursing blood test guidelines for serum electrolytes and glucose, renal function tests, liver tests, lipase, toxicological tests and beta Human Chorionic gonadotrophin levels. Order sets were revised with tests eliminated from the routine panels that were not felt to routinely contribute to patient care. The new guidelines were communicated to nursing staff in a series of educational sessions, and the revised guidelines were posted at nursing stations. Physician ordering practice was not changed. A pre-post evaluation compared the period 1 December 2014, - 30 November 2015 with 1 December 2015 - 30 November 2016. Clinical outcomes and patient wait times were not evaluated. Results: The use of tests in these categories decreased 32% between the two periods, at a net saving of $210, 246c. The largest savings came from total protein (73% decrease), Creatine kinase (68%), chloride (64%), glucose (49%), and albumin (47%). Sodium/Potassium testing decreased by only 13%. The only increase in test ordering recorded was AST (3% increase). Conclusion: Simply changing symptom driven order sets resulted in significant savings to the system. In the era of Choosing wisely regular review of lab order sets is indicated. Further study is needed to assess the effect of these changes on patient flow and on clinical outcome.
MP35: An educational and audit-and-feedback approach to decreasing unnecessary intravenous therapy in low-acuity emergency patients
Authors: Crowder K. , Del Castilho C. , Domm E. , Norrena L. , Nugent P.
Published: May 2018

Introduction: Intravenous (IV) therapy in the emergency department (ED) is associated with risk of harm from IV complications, higher ED monitoring requirements and increased ED length of stay (LOS), the latter a measure most cumbersome in lower-acuity patients that are eventually discharged from the ED. The aim of this quality improvement project was to evaluate the effectiveness of educational and audit-and-feedback interventions, with a goal of relative reduction of ED IV therapy by 20% over eight week periods, in lower-acuity patients in the high-turnover intake area of the ED who were discharged from the ED. Methods: The first cycle of the project was education about IV therapy use and alternatives in lower-acuity, ED patients (Canadian Triage Acuity Scale (CTAS) 3 and 4) from July 2 to August 31, 2017. Education was delivered through email information, posters, education sessions with nurse educators, and working groups sharing information. The second cycle of the project, from October 16 to December 15, 2017, also integrated an audit-and-feedback tool whereby physicians received their own pooled ordering data of IVs from the same period the previous year and then trial period as well pooled comparison averages for the physician group in the population of interest. Measures were the percentage of IVs ordered by physicians and administered by nurses in the population of interest in each time period. Results: From July 2 to August 31, 2017, when the intervention was education only, the rate of IV therapy changed from 31% to 37%, which reflects a 19% relative increase in IV use. In the beginning of the second cycle utilizing both education and audit-and-feedback interventions, from October 16 to December 15, 2017, 35% of patients had IV therapy. At the end of the second cycle, 25% of patients had IV therapy, a 28% relative decrease in IV therapy rates. When both cycles are reviewed sequentially, IV therapy rates decreased from 31% to 25%, a relative reduction of IV usage of 19%. Conclusion: In this quality improvement project, an educational initiative for the interdisciplinary team alone did not reduce IV use in lower-acuity patients. Concurrent education and audit-and-feedback interventions were more effective than education alone in decreasing IV therapy in appropriately selected patients in a tertiary ED.
MP41: Validity of the Canadian CT head rule age criterion for mild traumatic brain injury
Authors: Fournier N. , Émond M. , Le Sage N. , Gariépy C. , Fortier E. , Belhumeur V. , Prevost J.
Published: May 2018

Introduction: With a Canadian aging population, the prevalence of mild traumatic brain injury (mTBI) among elderly is increasing and the age criterion of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We evaluated if increasing the age criterion of the CCHR would maintain its validity. Methods: We conducted an historical cohort study using the medical charts of all patients 65 years old or more who consulted at a Level One Trauma Centre emergency department (ED) for a mTBI between 2010 and 2014. The main outcome measures were clinically important brain injury (CIBI) on Computed Tomography (CT) and the presence of the CCHR criteria. The clinical and radiological data collection was standardized. Univariate analysis was performed to measure the predictive capacities of modified age cut-offs at 70 and 75 years old. Results: Out of the 104 confirmed mTBI in this study, 32 (30,8%) had CIBI on CT scan. Sensitivity and specificity [C.I. 95%] of the CCHR were 100% [89.1 - 100] and 0% [0.0 5.0] for an age criterion of 65 years old and above; 100% [89.1 - 100] and 4,2% [0.9 11.7] for a modified criterion of 70 years old; 100% [89.1 - 100] and 13,9% [6.9 24.1] for 75 years old. Furthermore, for an age criterion of 80 and 85 years old, sensitivity was respectively 90,6% [75.0 98.0] and 75,0% [56.6 88.5]. Conclusion: In our cohort, increasing the age criterion of the CCHR for minor head injury to 75 years old would benefit ED by further reducing CT scans without missing CIBI. A larger prospective study is indicated to confirm the proposed modification.
MP43: Evaluation of an innovative web-based educational program to teach the management of alcohol withdrawal
Authors: Borgundvaag B. , Thompson C. , McLeod S. , Perelman S. , Lee S. , Carver S. , Dear T.
Published: May 2018

Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a web-based curriculum to teach clinicians how to accurately assess and treat AWS. Methods: This was a three-phase educational program consisting of a series of 3 e-learning modules of core competency material, in-person seminar to orient learners to high fidelity simulation, and summative evaluation in an OSCE setting using a standardized patient. To determine the ED impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the ED pre and post training. ED length of stay, total dose of benzodiazepines administered in the ED, and number of prescriptions and unit benzodiazepine doses given upon discharge were also recorded. Results: 74 nurses from an academic ED completed the AWS curriculum. There were 130 and 126 patients in the pre and post AWS training periods, respectively. Management of AWS was not compliant with CIWA-Ar protocol in 78 (60.0%) and 46 (36.5%) patients pre and post AWS training, respectively ( 23.5%; 95% CI: 11.3%, 34.7%), resulting in administration of benzodiazepine when it was not required, or not giving benzodiazepines with a CIWA-Ar score of 10. There was an average of 4 CIWA-Ar scores per patient in both the pre and post implementation periods. Prior to AWS training, 144/560 (25.5%) CIWA-Ar scores resulted in a breach of protocol, compared to 64/547 (11.7%) following AWS training ( 13.8%; 95% CI: 9.3%, 18.3%). Median total dose of benzodiazepines administered in the ED was lower after the implementation of the AWS curriculum (40mg vs 30mg; 10 mg; 95% CI: 0mg, 20mg). ED length of stay and the amount of benzodiazepines given to patients at discharge were similar between groups. Conclusion: This AWS curriculum appears to be an effective way to train ED clinicians on the proper administration of the CIWA-Ar protocol, and results in improved patient care.
MP44: TEC4Home heart failure: using home telemonitoring to decrease ED readmissions and clinical flow
Authors: Novak Lauscher H. , Ho K. , Cordeiro J. L. , Bhullar A. , Abu Laban R. , Christenson J. , Harps H. , Hawkins N. , Karim E. , Kim Sing C. , McGavin C. , Mitton C. , Smith T.
Published: May 2018

Introduction: Patients with Heart failure (HF) experience frequent decompensation necessitating multiple emergency department (ED) visits and hospitalizations. If patients are able to receive timely interventions and optimize self-management, recurrent ED visits may be reduced. In this feasibility study, we piloted the application of home telemonitoring to support the discharge of HF patients from hospital to home. We hypothesized that TEC4Home would decrease ED revisits and hospital admissions and improve patient health outcomes. Methods: Upon discharge from the ED or hospital, patients with HF received a blood pressure cuff, weight scale, pulse oximeter, and a touchscreen tablet. Participants submitted measurements and answered questions on the tablet about their HF symptoms daily for 60 days. Data were reviewed by a monitoring nurse. From November 2016 to July 2017, 69 participants were recruited from Vancouver General Hospital (VGH), St. Pauls Hospital (SPH) and Kelowna General Hospital (KGH). Participants completed pre-surveys at enrollement and post-surveys 30 days after monitoring finished. Administrative data related to ED visits and hospital admissions were reviewed. Interviews were conducted with the monitoring nurses to assess the impact of monitoring on patient health outcomes. Results: A preliminary analysis was conducted on a subsample of participants (n=22) enrolled across all 3 sites by March 31, 2017. At VGH and SPH (n=14), 25% fewer patients required an ED visit in the post-survey reporting compared to pre-survey. During the monitoring period, the monitoring nurse observed seven likely avoided ED admissions due to early intervention. In total, admissions were reduced by 20% and total hospital length of stay reduced by 69%. At KGH (n=8), 43% fewer patients required an ED visit in the post-survey reporting compared to the pre-survey. Hospital admissions were reduced by 20% and total hospital length of stay reduced by 50%. Overall, TEC4Home participants from all sites showed a significant improvement in health-related quality of life and in self-care behaviour pre- to 90 days post-monitoring. A full analysis of the 69 patients will be complete in February 2018. Conclusion: Preliminary findings indicate that home telemonitoring for HF patients can decrease ED revisits and improve patient experience. The length of stay data may also suggest the potential for early discharge of ED patients with home telemonitoring to avoid or reduce hospitalization. A stepped-wedge randomized controlled trial of TEC4Home in 22 BC communities will be conducted in 2018 to generate evidence and scale up the service in urban, regional and rural communities. This work is submitted on behalf of the TEC4Home Healthcare Innovation Community.
P001: Age-adjusted D-dimer and two-site compression point of care ultrasonography to rule out acute deep vein thrombosis - a pilot study
Authors: Alqaydi K. , Turner J. , Robichaud L. , Hamad D. , Xue X. , Afilalo M.
Published: May 2018

Introduction: Deep vein thrombosis (DVT) can lead to significant morbidity and mortality if not diagnosed and treated promptly. Currently, few methods aside from venous duplex scanning can rule out DVT in patients presenting to the Emergency Department (ED). Current screening tools, including the use of the subjective Wells score, frequently leads to unnecessary investigations and anticoagulation. In this study, we sought to determine whether two-site compression point-of-care ultrasound (POCUS) combined with a negative age-adjusted D-dimer test can accurately rule out DVT in ED patients irrespective of the modified Wells score. Methods: This is a single-center, prospective observational study in the ED of the Jewish General Hospital in Montreal. We are recruiting a convenience sample of patients presenting to the ED with symptoms suggestive of DVT. All enrolled patients are risk-stratified using the modified Wells criteria for DVT, then undergo two-site compression POCUS, and testing for age-adjusted D-dimer. Patients with DVT unlikely according to modified Wells score, negative POCUS and negative age-adjusted D-dimer are discharged home and receive a three-month phone follow-up. Patients with DVT likely according to modified Wells score, a positive POCUS or a positive age-adjusted D-dimer, will undergo a venous duplex scan. A true negative DVT is defined as either a negative venous duplex scan or a negative follow-up phone questionnaire for patients who were sent home without a venous duplex scan. Results: Of the 42 patients recruited thus far, the mean age is 56 years old and 42.8% are male. Twelve (28.6%) patients had DVT unlikely as per modified Wells score, negative POCUS and negative age-adjusted D-dimer and were discharged home. None of these patients developed a DVT on three-month follow-up. Thirty patients (71.4%) had either a DVT likely as per modified Wells score, a positive POCUS or a positive age-adjusted D-dimer and underwent a venous duplex scan. Of those, six patients had a confirmed DVT (3 proximal & 3 distal). POCUS detected all proximal DVTs, while combined POCUS and age-adjusted D-dimer detected all proximal and distal DVTs. None of the patients with a negative POCUS and age-adjusted D-dimer were found to have a DVT. Conclusion: Two-site compression POCUS combined with a negative age-adjusted D-dimer test appears to accurately rule out DVT in ED patients without the need for follow-up duplex venous scan. Using this approach would alleviate the need to calculate the Wells score, and also reduce the need for radiology-performed duplex venous scan for many patients.
P002: Prehospital analgesia with intra-nasal ketamine: a randomized double-blind pilot study
Authors: Andolfatto G. , Innes K. , Dick W. , Jenneson S. , Zed P. J. , Stenstrom R.
Published: May 2018

Introduction: Primary care paramedics (PCPs) have limited options to provide analgesia during transport thus timely pain relief is often significantly delayed. Inhaled nitrous oxide is considered usual care for PCPs, but is limited in effectiveness. Intranasal (IN) ketamine has been shown to provide effective analgesia with no deleterious effects on cardiorespiratory function thus may provide rapid, easily-administered and well-tolerated analgesia in prehospital transports. Methods: This was a randomized double-blind pilot series. Patients with an acute painful condition reporting a pain score of 5 or more on an 11-point verbal numeric rating scale (VNRS) were included. Exclusion criteria were age under 18 years, known intolerance to ketamine, non-traumatic chest pain, altered mental status, pregnancy and nasal occlusion. Patients were randomized to 0.75 mg/kg of IN ketamine or IN saline. All patents received inhaled nitrous oxide. The primary outcome was the proportion of patients experiencing a reduction in VNRS pain score of two points or more (clinically significant pain reduction) at 30 minutes. Secondary outcomes were patient-reported comfort, patient and provider satisfaction, and incidence of adverse events. Results: 40 patients were enrolled, 20 in each group. 80% of IN ketamine patients compared to 60% of placebo patients reported a 2-point reduction in VNRS pain score by 30 minutes. 50% of ketamine vs 25% of placebo patients reported feeling moderately or much better. 85% of ketamine vs 75% of placebo patients reported any improvement in subjective comfort. 80% of ketamine patients reported minor adverse effects compared to 52% of placebo patients. No serious adverse effects were reported. Conclusion: The addition of IN ketamine to usual care with nitrous oxide appears to result in a greater proportion of patients reporting a clinically significant reduction in VNRS pain score and improved subjective comfort, with a greater incidence of minor adverse effects. These findings will be used to power a definitive randomized double-blind trial.
P006: Patient passports in the emergency department: a scoping review
Authors: Bennett C. B. , Curran J.
Published: May 2018

Introduction: Discharge communication in the emergency department occurs frequently and has been identified as an important, underestimated problem. Tools, such as patient or caregiver-held passports have been used in other departments to improve communication and facilitate provider and patient decision making. The objective of this review was to identify what modalities, methods and designs have been used and evaluated when implementing a communication tool or passport type document in the emergency department setting. Methods: This review was conducted following Joanna Briggs Institute methodology. Iterative steps included identifying the research question, identifying relevant studies, data extraction and synthesis. Keywords and indexed terms were used to search PubMed, Cinahl, Embase and Web of Science. The reference list of all identified reports and articles from that search were reviewed for additional studies and a hand search of the last 5 years of Annals of Emergency Medicine and the Canadian Journal of Emergency Medicine was completed. Inclusion criteria were set to select studies investigating either patients, caregivers or health care providers use of passports, communication documents or journals with the goal of improving any aspect of communication in the emergency department setting. Results: Of the 81 potential publications screened, only 4 met inclusion criteria for extraction. 1 reviewed a passport that aimed at pediatric pain management in settings that include the emergency department, 2 of the publications reported on the same project which developed a passport for asthma patients and 1 discussed a passport for patients with learning disabilities. All the included publications were published in and discuss passports that were developed for use in the UK. Descriptions of implementation, evaluation and perception of the passports in these publications was limited. Conclusion: This scoping review has revealed a major gap in the current literature on communication tools in the emergency department, a department where communication, especially about discharge is of utmost importance. The included studies focused on very different patient populations and aim to improve different outcomes and therefore dont allow us to make for passports aimed at helping the general emergency department population.
P009: Emergency department overcrowding associated with increased door-to-ecg time in patients with chest pain
Authors: Bhatia M. , Hopman W. , Mckaigney C. , Loricchio D. , Hall A. K.
Published: May 2018

Introduction: Emergency Department (ED) overcrowding has been shown to delay time sensitive tests and therapies. North American guidelines call for Door-to ECG (DTE) times to be <10min in patients presenting with chest pain as delays have been shown to lead to poorer patient outcomes. We hypothesize that increased ED crowding will increase the DTE times. Methods: This was a retrospective cohort study from July 2015-May 2016 at a single tertiary care Canadian ED (53000 visits per year). Data were extracted from the ED information system (EDIS) which contains an organized record of ED activity for each visit. Our selection criteria screened for patients presenting with complaints that included chest pain, chest heaviness, chest tightness and chest burning. The primary outcome of the study was the association between ED occupancy and DTE time, which was measured using a non-parametric Spearman correlation. Multivariable linear regression models controlling for age and sex were developed for both time in minutes, and the log transformed time in minutes. Results: There were 2479 ECGs done on patients presenting with chest pain that met inclusion criteria. The median DTE time was 55.1 minutes. There was a significant positive association between DTE time and ED occupancy (rho=.133, p<0.001). DTE time increased by 0.64 minutes (or approximately 0.4%) for each additional patient in the ED, p<0.001. Additionally, younger age and female sex were also associated with increased DTE time. Conclusion: Increased ED occupancy was correlated with longer DTE times at a single Canadian ED, even after controlling for age and sex. This study provides an example of the negative consequences of ED overcrowding.
P012: Why did you leave? Contacting left without being seen patients to understand their emergency department experience
Authors: Brar B. , Stempien J. , Goodridge D.
Published: May 2018

Introduction: As experienced in Emergency Departments (EDs) across Canada, Saskatoon EDs have a percentage of patients that leave before being assessed by a physician. This Left Without Being Seen (LWBS) group is well documented and we follow the numbers closely as a marker of quality, what happens after they leave is not well documented. In Saskatoon EDs, if a CTAS 3 patient that has not been assessed by a physician decides to leave the physician working in the ED is notified. The ED physician will: try to talk to the patient and convince them to stay, can assess the patient immediately if required, or discuss other appropriate care options for the patient. In spite of this plan patients with a CTAS score of 3 or higher (more acute) still leave Saskatoon EDs without ever being seen by a physician. Our desire was to follow up with the LWBS patients and try to understand why they left the ED. Methods: Daily records from one of the three EDs in Saskatoon documenting patients with a CTAS of 3 or more acute who left before being seen by a physician were reviewed over an eight-month period. A nurse used a standardized questionnaire to call patients within a few days of their ED visit to ask why they left. If the patients declined to take part in the quality initiative the interaction ended, but if they agreed a series of questions was asked. These included: how long they waited, reasons why they left, if they went somewhere else for care and suggestions for improvement. Descriptive statistics were obtained and analyzed to answer the above questions. Results: We identified 322 LWBS patients in an eight-month time period as CTAS 3 or more acute. We were able to contact 41.6% of patients. The average wait time was 2 hours and 18 minutes. The shortest wait time was 11 minutes, whereas the longest wait time was 8 hours and 39 minutes. It was found that 49.1% of patients went to another health care option (Medi-Clinic or another ED in Saskatoon) within 24hrs of leaving the ED. Long wait times were cited as the number one reason for leaving. Lack of better communication from triage staff regarding wait time expectations was cited as the top response for perceived roadblocks to care. Reducing wait times was cited as the number one improvement needed to increase the likelihood of staying. Conclusion: The Saskatoon ED LWBS patient population reports long wait times as the main reason for leaving. In order to improve the LWBS rates, improving communication and expectations regarding perceived wait times is necessary. The patient perception of the ED experience is largely intertwined with wait times, their initial interaction with triage staff, and how easily they navigate our very busy departments. Therefore, it is vital that we integrate the patient voice in future initiatives geared towards improving health care processes.
P013: Management of intimate partner violence in the emergency department
Authors: Brown R. , Sampsel K. , Stiell I.G.
Published: May 2018

Introduction: Intimate partner violence (IPV) is a serious public health concern with complex medico-legal implications and a wide range of morbidity. While the ED is often the primary access point for these patients, IPV is under-recognized. Our objectives were to describe the characteristics of female IPV patients in the ED and determine the assessment and management patterns of physicians at a tertiary care academic ED. Methods: We conducted a health records review of adult (>18years) female patients seen at a tertiary care hospital ED presenting with evidence of IPV from January to September 2016. A combined search strategy of hospital records and Sexual Assault and Partner Abuse Care Program (SAPACP) patient rosters was used to identify study subjects. Data were collected for patient demographic/presenting characteristics, assault characteristics, and patterns of referral, management and patient disposition/discharge. Descriptive statistics were generated. Results: 100 patients met inclusion criteria with; mean age 35.1, female 100.0%, arrival by ambulance 53.0%, and mean CTAS level of 2.4. Abuse screening was completed at triage only 24.0% of the time. Presenting complaints were varied, with the most common being injury or trauma (32.0%). Most patients were only identified from the SAPACP roster. Patients reported strangulation, a strong predictor of future homicide, in 34.0% of cases. Admission to hospital occurred in 7.0% of cases with 19.0% involving specialist consultation and 7.0% leaving against medical advice or without being seen. Legal interactions including police involvement occurred 72.0% of the time and Childrens Aid Society was involved in 26.0% of cases. The final diagnosis was recorded as IPV or equivalent in only 49.0% of cases; the remainder were discharged with a final diagnosis of injury/trauma (26.0%), sexual assault (6.0%), somatic complaint (6.0%), mental health (8.0%), substance use/abuse (3.0%) or other (2.0%). Conclusion: Our study highlights that IPV is a common and heterogeneous entity with a wide spectrum of presentations and morbidity. Strangulation rates were high and are associated with increased risk of homicide. IPV is currently under-recognized and continues to carry stigma as ER physicians only recorded a discharge diagnosis of IPV or equivalent in half of cases. Educational strategies are required to highlight the importance of IPV to ED staff.