bluuebunny/crossref_metadata_2025 huggingface dataset:
Hypersurfaces quasi-invariant by codimension one foliations
Authors: Pereira Jorge Vitório , Spicer Calum
Published: May 2019

We present a variant of the classical Darboux-Jouanolou Theorem. Our main result provides a characterization of foliations which are pull-backs of foliations on surfaces by rational maps. As an application, we provide a structure theorem for foliations on 3-folds admitting an infinite number of extremal rays.
Inheritance of resistance to Cercospora leaf spot disease of cowpea [Vigna unguiculata (L.) Walp]
Authors: Omoigui Lucky O. , Arrey Matilda O. , Kamara Alpha Y. , Danmaigona Catherine C. , Ekeruo Godspower , Timko Michael P.
Published: May 2019

Cercospora leaf spot (CLS) caused by Pseudocercospora cruenta (Sacc.) is an important disease affecting cowpea production in Nigeria. Understanding the genetic nature of CLS is an important step in developing an effective breeding strategy. This study investigated the inheritance of CLS disease in cowpea under natural epiphytotic field condition involving two CLS resistant parents (IT99K-573-1-1, IT99K216-24) and a CLS susceptible parent (UAM09-1055-6). The parental lines, F1, BC1P1, BC1P2, F2 and F3 generations were used to study the genetic nature and to detect SSR markers closely linked with the CLS resistance gene(s) using bulked segregant analysis (BSA). The result showed that F1 populations involving UAM09-1055-6 × IT99K-573-1-1 and UAM09-1055-6 × IT99K-216-24 were resistant to CLS in the 2 crosses suggesting the presence of gene dominance in the control of the disease. The observed segregating ratio of F2 populations fits the Mendalian ratio 3:1. The plants reaction to the disease in the backcross progeny test involving the resistant parent were all uniformly resistant, whereas those involving the susceptible parent segregated into ratio 1:1. The F3 generations, which segregated into ratio 1:2:1 further confirmed that resistance was controlled by a single dominant gene in the crosses studied. Heritability estimates varied from 81 to 97%. BSA showed that SSR marker code named RB24 of lima bean and validated on F2 population discriminated between resistance and susceptibility to CLS. Hence RB24 could be a useful marker for marker-assisted selection in CLS resistance breeding in cowpea.
The endpoint epidemic of IoT – just a bad dream?
Authors: Giese Sascha
Published: May 2019

Over the past decade we've heard a lot of concern from security vendors about the rise of the Internet of Things (IoT) and the growth of smart devices. On a daily basis, technology professionals are struggling to keep their organisations secure, even though the endpoint epidemic that has kept experts up at night hasn't fully manifested itself in the way we feared.

The growth of the Internet of Things (IoT) has been a key theme of the past few years but the endpoint epidemic that has kept experts up at night hasn't fully manifested itself in the way we feared.

Yet despite its slow burn, IoT should remain a top priority for today's cyber security professionals. A self-healing, automated network can detect threats, keep data from being compromised and reduce downtime. Infrastructure teams within today's digital businesses need to operate at a speed that leaves little room for manual updates and almost certainly requires automation, suggests Sascha Giese at SolarWinds.
Editorial
Authors: Barrett Steve
Published: May 2019

Hydrogen mobility alliances are facilitating the deployment of both hydrogen refueling infrastructure and fuel cell electric vehicles in many countries, and it is good to see ongoing progress in these national initiatives.
LO59: Retention of critical procedural skills post-simulation training: a systematic review
Authors: Legoux C. , Gerein R. , Boutis K. , Plint A.
Published: May 2019

Introduction: Short-term gains in knowledge and skills of critical emergency procedures are demonstrated after simulation, but there is uncertainty regarding long term retention. Our objective was to determine whether simulation of critical emergency procedures promotes long term retention of procedural skills in non-surgical physicians likely to perform them. Methods: MEDLINE and Embase (from start of database to June 2018) and the CENTRAL Trials Registry of the Cochrane Collaboration (May 2018 Issue) were searched using a peer-reviewed strategy. Studies were eligible if they (1) were observational cohorts, quasi-experimental or randomized controlled trials, (2) assessed intubation, cricothyrotomy, periocardiocentesis, tube thoracostomy or central line placement performance by non-surgical physicians, (4) utilized any form of simulation (all levels of realism and technology), and (4) assessed skill performance immediately after and at ≥3 months post-simulation. There was no language restriction. Two reviewers independently assessed article eligibility. One reviewer extracted data and assessed study quality. Primary outcome was skill performance 3 months post-simulation. Secondary outcomes included skill performance at 6 and ≥12 months post-simulation, and skill competency at 3 months post-simulation. Results: 1370 citations were identified. 12 studies were eligible. Methodological quality was uniformly poor with high risk of bias, lack of defined primary outcomes, inadequate sample sizes, and non-standardized, unvalidated tools of unclear clinical significance. Given significant heterogeneity in design, populations, procedures, and outcome timing, a narrative synthesis of results was undertaken. In 10 studies participants’ performance at 3, 6 and 12 months retention testing remained above baseline assessment. However, 3 studies showed a significant decrease in performance at 3 months post-simulation compared to immediately post-simulation. Performance was also lower in 2 studies at 6 months post-simulation, and 2 studies at ≥12 months post-simulation. Four studies assessed competency and 3 demonstrated maintenance of competency. Conclusion: There was significant heterogeneity and poor methodological quality among the eligible studies. Results were conflicting for retention of procedural skills and competency. Future directions should include development of robust assessment tools, and improved research methodology of simulation education targeted at critical procedural skills.
LO65: Frailty and associated outcomes among emergency department patients requiring endotracheal intubation
Authors: Fernando S. , McIsaac D. , Rochwerg B. , Bagshaw S. , Seely A. , Perry J. , Dave C. , Tanuseputro P. , Kyeremanteng K.
Published: May 2019

Introduction: Risk-stratification of patients requiring endotracheal intubation and mechanical ventilation in the Emergency Department (ED) is necessary for informed discussions with patients regarding goals-of-care. Frailty is a clinical state characterized by reduced physiologic reserve, and resulting from accumulation of physiological stresses and comorbid disease. Frailty is increasingly being identified as an important independent predictor of outcome among critically ill patients. Our objective was to identify the impact of clinical frailty (defined by the Clinical Frailty Scale [CFS]) on in-hospital mortality and resource utilization of ED patients requiring endotracheal intubation and mechanical ventilation. Methods: We analyzed a prospectively collected registry (2011-2016) of patients requiring endotracheal intubation in the ED at two academic hospitals and six community hospitals. We included all patients ≥18 years of age, who survived to the point of ICU admission. All patient information, outcomes, and resource utilization were stored in the registry. CFS scores were obtained through chart abstraction by two blinded reviewers. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model, controlling for confounding variables (including patient sex, comorbidities, and illness severity). We defined “frailty” as a CFS ≥ 5. Results: 4,622 patients were included. Mean age was 61.2 years (SD: 17.5), and 2,614 (56.6%) were male. Frailty was associated with increased risk of in-hospital mortality, as compared to those who were not frail (adjusted odds ratio [OR] 2.21 [1.98-2.51]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted OR 1.78 [1.56-2.01]) among patients initially from a home setting. Frail patients were more likely to fail extubation during their hospitalization (adjusted OR 1.81 [1.67-1.95]) and were more likely to require tracheostomy (adjusted OR 1.41 [1.34-1.49]). Conclusion: Presence of frailty among ED patients requiring endotracheal intubation and mechanical ventilation was associated with increased in-hospital mortality, discharge to long-term care, extubation failure, and tracheostomy. ED physicians should consider the impact of frailty on patient outcomes, and discuss associated prognosis with patients prior to intubation.
LO85: Development of a competency based assessment tool for emergency department point of care ultrasound
Authors: McKaigney C. , Bell C. , Hall A.
Published: May 2019

Innovation Concept: Assessment of residents' Point of Care Ultrasound (PoCUS) competency currently relies on heterogenous and unvalidated methods, such as the completion of a number of proctored studies. Although number of performed studies may be associated with ability, it is not necessarily a surrogate for competence. Our goal was to create a single Ultrasound Competency Assessment Tool (UCAT) using domain-anchored entrustment scoring. Methods: The UCAT was developed as an anchored global assessment score, building on a previously validated simulation-based assessment tool. It was designed to measure performance across the domains of Preparation, Image Acquisition, Image Optimization, and Clinical Integration, in addition to providing a final entrustment score (i.e., OSCORE). A modified Delphi method was used to establish national expert consensus on anchors for each domain. Three surveys were distributed to the CAEP Ultrasound Committee between July-November 2018. The first survey asked members to appraise and modify a list of anchor options created by the authors. Next, collated responses from the first survey were redistributed for a re-appraisal. Finally, anchors obtaining >65% approval from the second survey were condensed and redistributed for final consensus. Curriculum, Tool or Material: Twenty-two, 26, and 22 members responded to the surveys, respectively. Each anchor achieved >90% final agreement. The final anchors for the domains were: Preparation – positioning, initial settings, ensures clean transducer, probe selection, appropriate clinical indication; Image Acquisition – appropriate measurements, hand position, identifies landmarks, visualization of target, efficiency of probe motion, troubleshoots technical limitations; Image Optimization – centers area of interest, overall image quality, troubleshoots patient obstacles, optimizes settings; Clinical Integration – appropriate interpretation, understands limitations, utilizes information appropriately, performs multiple scans if needed, communicates findings, considers false positive and negative causes of findings. Conclusion: The UCAT is a novel assessment tool that has the potential to play a central role in the training and evaluation of residents. Our use of a modified Delphi method, involving key stakeholders in PoCUS education, ensures that the UCAT has a high degree of process and content validity. An important next step in determining its construct validity is to evaluate the use of the UCAT in a multi-centered examination setting.
LO93: Implementation of sepsis order sets to decrease the time to antibiotics in the emergency department: a quality improvement initiative
Authors: Akilan K. , Teo V. , Hefferon D. , Verma A.
Published: May 2019

Background: Sepsis is a life-threatening syndrome, and delays to appropriate antibiotic therapy increases mortality. Order sets have shown decrease in time to antibiotics in pneumonia, and in sepsis, the implementation of order sets resulted in more intravenous fluids, appropriate initial antibiotics and lower mortality. Aim Statement: The goal was to create an order set for an approach to septic patients, to improve sepsis management. We sought to improve time from triage to first antibiotics, by 15 minutes, for Emergency Department (ED) patients with sepsis in three months after implementation compared to three months before. Measures & Design: We used a literature review, as well as comparison to existing order sets at other EDs to design our initial order set. We underwent multiple revisions based on stakeholder feedback. We educated physician and nursing teams about the order sets, although use was ultimately at physician discretion. We implemented the order set on April 9, 2017. After three months, an electronic retrospective chart review identified patients with a final sepsis diagnosis admitted to the critical care unit. For each patient, we captured triage time using the electronic record, and time to antibiotics from when the antibiotic was taken out of the medication cart. Finally, utilization of order sets was checked via manual chart audit. Evaluation/Results: A run chart did not demonstrate any shifts or trends suggesting a change after implementation. Median time to antibiotics in minutes, 3 months prior (n = 45) and post (n = 55) intervention, increased from 245 to 340 minutes, although the range was very large. Chart audits demonstrated clinicians were not using the order sets. There was 10% usage for 2 of the months and 0% usage the other month, post-intervention. Disucssion/Impact: There was insufficient uptake of the Sepsis Order Set by the Sunnybrook ED to result in any impact on time to antibiotics. Order sets require more than just implementation to be effective. Difficulties in implementation were due to the document not being readily available to physicians. To mediate, we have organized nursing staff to attach the order set onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.
MP08: The frequency of emergency departments visits for patients with end-of-life conditions: a call for action
Authors: Kirkland S. , Kruhlak M. , Garrido Clua M. , Villa-Roel C. , Couperthwaite S. , Brisebois A. , Elwi A. , O'Neil B. , Duggan S. , Rowe B.
Published: May 2019

Introduction: An increasing number of patients with end-stage diseases present to emergency departments (EDs) for physical, spiritual, psychological and social care. The objective of this study was to identify patients with end-stage diseases with palliative care (PC) needs and document their frequency of ED visits. Methods: This prospective cohort study was conducted in two Canadian EDs. Using a modified palliative care screening tool, volunteer ED physicians were asked to identify adult patients with end-stage, chronic conditions including cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), heart failure (HF), cirrhosis, dementia and/or progressive central nervous system (PCNS) disease. Demographic data were collected from these tools and data regarding patients’ visits in both the 6 months prior to and 30 days following their index visits were collected from the ED Information System. Bivariate analyses were completed using Student's t and chi-square test. Results: A total of 663 patients with end-stage illness were identified; 338 (51%) were female and the median age was 76 (IQR: 63, 85). Cancer was the most common presentation (41%), followed by dementia (23%), COPD (16%), HF (9%), CKD (9%), PCNS disease (9%) and cirrhosis (7%). These patients made a total of 1277 visits in the 6 months prior to and 288 in the 30 days following the index visit. Patients presenting to the EDs with cancer (p = 0.001), cirrhosis (p = 0.005) and CKD (p = 0.03) were more likely to visit an ED in the 6 months prior to their index visit. In contrast, patients presenting with dementia (p < 0.0001) and PCNS disease (p = 0.02) were significantly less likely to present to an ED in the 6 months prior to their index visit. Patients presenting with cirrhosis or CKD had the highest average number of ED visits in the 6 months prior to their index visit (cirrhosis: 4.59 visits, SD: 3.8, p < 0.0001; CKD: 4.39 visits, SD: 3.8, p = 0.0001). Of these patients, those presenting with end-stage cirrhosis were significantly more likely to make a return visit to an ED within 30 days after their index visit (p = 0.014). Conclusion: Cancer is the most common condition for patients with end-stage, chronic illnesses in these EDs. Those presenting with cirrhosis or CKD are at a significantly higher risk of repeat visits to the EDs. This study has identified potential deficits in care and can serve as a baseline for future intervention studies.
MP13: Association between the quantity of subcutaneous fat and the inter-device agreement of two tissue oximeters
Authors: Cournoyer A. , Cossette S. , Paquet J. , Daoust R. , Marquis M. , Notebaert É. , Iseppon M. , Chauny J. , Denault A.
Published: May 2019

Introduction: Near-infrared spectroscopy (NIRS) can be used to monitor the oxygen saturation of hemoglobin in any given superficial tissue. However, the measurements provided by different oximeters can vary a lot. Little is known about the specific patient characteristics that could affect the inter-device agreement of tissular oximeters. This study aimed to evaluate the association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement of two tissue oximeters, the INVOS 5100c and the Equanox 7600. Methods: In this prospective cohort study, tissue saturations and skinfold thickness were measured at four different sites on both sides of the body in healthy adult (≥18 years old) volunteers. The association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement (absolute difference between the oximetry values provided by the two oximeters) was first assessed with a Pearson's correlation and a scatter plot. Subsequently, a linear mixed model was used to evaluate the impact of the subcutaneous fat and other covariables (age, sex) on the inter-device agreement while adjusting for the repeated measurements across different sites for the same volunteers. Results: From January to March 2015, 53 healthy volunteers were included in this study with ages ranging between 20 and 81 years old, on which a total of 848 measures were taken. Higher skinfold measures were associated with an increase in the difference between measures provided by both oximeters (Slope = -0.59, Pearson correlation coefficient = -0.51, p < 0.001). This observed association persisted in a linear mixed model (-0.48 [95% confidence interval {CI}-0.61 to -0.36], p < 0.001). The sex of the volunteers also influenced the inter-oximeter agreement (Women:-5.77 [95%CI -8.43 to -3.11], p < 0.001), as well as the forearm sites (Left forearm: −7.16 [95%CI -9.85 to –4.47], p < 0.001; right forearm: −7.01 [95%CI -9.61 to −4.40], p < 0.001). Conclusion: The quantity of subcutaneous fat, as well as the sex of the volunteers and the measurement sites, impacted the inter-device agreement of two commonly used oximeters. Given these findings, monitoring using tissue oximetry should be interpreted with great care when there is a significant quantity of subcutaneous fat.
MP24: The University of Ottawa's Department of Emergency Medicine pre-internship boot camp: a descriptive review
Authors: Patrick S. , Mastoras G. , Krywenky A.
Published: May 2019

Innovation Concept: Emergency Medicine (EM) residency programs in Canada have transitioned to competency based medical education and the first stage of the curriculum focuses on standardizing learner competency. Pre-internship boot camps provide a focused opportunity to assist with this standardization prior to residency training. The objective of this descriptive review was to describe our institution's EM pre-internship boot camp in the context of current literature and to summarize the state of EM boot camp curricula across all reported EM residency programs. Methods: The description of our two-day boot camp included its curriculum design, required preparation and resources, and a detailed timeline of each day's events. To compare our boot camp to current literature, a comprehensive search of both primary and gray literature was performed. Curriculum, Tool or Material: Our institution's boot camp is two days of teaching focused on clinical knowledge and procedural competency, with a large component centered on simulation. Day one consisted of an introduction to the boot camp, a review of crisis resource management principles and advanced cardiac life support (ACLS) algorithms, ACLS simulation sessions, and small group skill sessions on common emergency department procedures. Day two contained a point of care ultra sound lecture, an ultrasound guided central venous catheterization session, pigtail and chest tube insertion sessions, and high-fidelity simulation cases. In comparison to the other pre-internship boot camps that were identified in the literature, our boot camp offers a unique focus and format. Conclusion: This review is the first to report on an EM-specific boot camp at a non-American institution, and it provides a framework for the development and refinement of pre-internship EM boot camps at other universities.
MP26: Development and evaluation of a novel emergency physician fan-out mechanism at an urban centre for use in mass casualty incidents
Authors: Melegrito J. , Granberg B. , Hanrahan K.
Published: May 2019

Background: Understaffing in mass casualty incidents limits flow in the overwhelmed emergency department, which is further compounded by inefficient use of those same human resources. Process mapping analysis of a “Code Orange” exercise at a tertiary academic hospital exposed the failures of telephone-based emergency physician fan-out protocols to address these issues. As such, a quality improvement and patient safety initiative was undertaken to design, implement, and evaluate a new mass casualty incident fan-out mechanism. Aim Statement: By February 2019, emergency physician fan-out will be accomplished within 1 hour of Code Orange declaration, with a response rate greater than 20%. Measures & Design: Process mapping of a Code Orange simulation highlighted telephone fan-out to be ineffective in mobilizing emergency physicians to provide care in mass casualty incidents: available staff were pulled from their usual duties to help unit clerks unsuccessfully reach off-duty physicians by telephone for hours. Stakeholders subsequently identified automation and computerization as a compelling change idea. A de-novo automated bidirectional text-messaging system was thus developed. Early trials were analyzed for process measures including fan-out speed, unit clerk involvement, and physician response rate, with further large-scale tests planned for early 2019. Evaluation/Results: Only 50% of telephone fan-out was completed after a 2-hour exercise despite 3 staff supplementing the 2 on-shift unit clerks, with a 4% physician response rate. In contrast, data from initial trials of the automated system suggest that full fan-out can be performed within 1 hour of Code Orange declaration and require only 1 unit clerk, with text-messages projected to yield higher physician response rates than telephone calls. Early findings have thus far affirmed stakeholder sentiments that automating fan-out can improve speed, unit clerk efficiency, and physician response rate. Discussion/Impact: Automated text-message systems can expedite fan-out protocol in mass casualty incidents, relieve allied health staff strain, and more reliably recruit emergency physicians. Large-scale trials of the novel system are therefore planned for early 2019, with future expansion of the protocol to other medical personnel under consideration. Thus, automated text-message systems can be implemented in urban centres to improve fan-out efficiency and aid overall emergency department flow in mass casualty incidents.
MP31: Safely reducing emergency physician admission rate through audit and feedback
Authors: Barclay N.
Published: May 2019

Background: Most admissions to hospitals occur through the emergency department (ED). The impact of emergency physicians’ decisions to admit a patient to hospital can have wide ranging effects on health care spending, hospital congestion and patient outcomes. A growing body of evidence shows that outpatient management of conditions such as diverticulitis, heart failure and pulmonary embolism is both safe, effective and can reduce costs. Aim Statement: To support emergency staff in making safe, informed decisions to appropriately reduce admission rates without increasing the rate of patients returning and being admitted. Measures & Design: Significant variability in admission rates between emergency physicians exists and no correlation between actual and self-reported admission rates is observed. One means to change behavior is through audit and feedback, however a Cochrane review on this topic concluded that it was only effective if specific conditions were met; findings which were incorporated into this project. An audit tool was created comparing individual physicians’ admission and “bounce back” rates to their peers. The tools contained averages for the individual and site for admission and bounce back rates and were shared with physicians every 2 months. Physicians were divided into three equal groups, low, medium and high admitters and targets established. Department heads met with high admitters. Evaluation/Results: The project was started in September 2016. Admission rates in the three physician groups were compared in the ten months before September 2016 (prior) and after January 2017 (post). September to December 2016 was considered the “rollout” period and not included in the analysis. Significance was tested using a Permutation test and a p-value cut off level of 5%. Nine emergency departments took part. Seven sites experienced a significant decrease in the admission rate of top admitters, three showed a significant increase in the rate of low admitters and two showed a significant increase in the rate of medium admitters. Pooled results showed a decrease in the admission rates of the top admitters and no significant change to the medium or low admitters. Discussion/Impact: Comparing the pre- and post-periods yielded a decrease in admissions of 773 patients on an annualized basis. The impact of the change in the top five highest admitters at the biggest three hospitals estimated an annualized beds savings of 25.3 beds.
MP35: Acceptability of older patients’ self-assessment in the emergency department (ACCEPTED) – a randomized cross-over trial
Authors: Boucher V. , Lamontagne M. , Lee J. , Carmichael P. , Déry J. , Émond M.
Published: May 2019

Introduction: It is recommended that seniors consulting to the Emergency Department (ED) undergo a comprehensive geriatric screening, which is difficult for most EDs. Patient self-assessment using electronic tablet could be an interesting solution to this issue. However, the acceptability of self-assessment by older ED patients remains unknown. Assessing acceptability is a fundamental step in evaluating new interventions. The main objective of this project is to compare the acceptability of older patient self-assessment in the ED to that of a standard assessment made by a professional, according to seniors and their caregivers. Methods: Design: This randomized crossover design cohort study took place between May and July 2018. Participants: 1) Patients aged ≥65 years consulting to the ED, 2) their caregiver, when present. Measurements: Patients performed self-assessment of their frailty, cognitive and functional status using an electronic tablet. Acceptability was measured using the Treatment Acceptability and Preferences (TAP) questionnaires. Analyses: Descriptive analyses were performed for sociodemographic variables. Scores were adjusted for confounding variables using multivariate linear regression. Thematic content analysis was performed by two independent analysts for qualitative data collected in the TAP's open-ended question. Results: A total of 67 patients were included in this study. Mean age was 75.5 ± 8.0 and 55.2% of participants were women. Adjusted mean TAP scores for RA evaluation and patient self-assessment were 2.36 and 2.20, respectively. We found no difference between the two types of evaluations (p = 0.0831). When patients are stratified by age groups, patients aged 85 and over (n = 11) showed a difference between the TAPs scores, 2.27 for RA evaluation and 1.72 for patient self-assessment (p = 0.0053). Our qualitative data shows that this might be attributed to the use of technology, rather than to the self-assessment itself. Data from 9 caregivers showed a 2.42 mean TAP score for RA evaluation and 2.44 for self-assessment. However, this relatively small sample size prevented us to perform statistical tests. Conclusion: Our results show that older patients find self-assessment in the ED using an electronic tablet just as acceptable as a standard evaluation by a professional.
MP49: Prehospital oxygen administration to suspected acute myocardial infarction patients: a systematic review and meta-analysis
Authors: Greene J. , Welsford M. , Ainsworth C. , Lambert L. , Wong G. , Cantor W.
Published: May 2019

Introduction: Oxygen is commonly administered to prehospital patients presenting with acute myocardial infarction (AMI). We conducted a systematic review to determine if oxygen administration, in AMI, impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central, clinicaltrials.gov and ISRCTN for relevant randomized controlled trials and observational studies comparing oxygen administration and no oxygen administration. The outcomes of interest were: mortality (≤30 days, in-hospital, and intermediate 2-11 months), infarct size, and major adverse cardiac events (MACE). Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. A meta-analysis was performed using RevMan 5 software. Results: Our search yielded 1192 citations of which 48 studies were reviewed as full texts and a total of 8 studies were included in the analysis. All evidence was considered low or very low quality. Five studies reported on mortality finding low quality evidence of no benefit or harm. Low quality evidence demonstrated no benefit or harm from supplemental oxygen administration. Similarly, no benefit or harm was found in MACE or infarct size (very low quality). Normoxia was defined as oxygen saturation measured via pulse oximetry at ≥90% in one recent study and ≥94% in another. Conclusion: We found low and very low quality evidence that the administration of supplemental oxygen to normoxic patients experiencing AMI, provides no clear harm nor benefit for mortality or MACE. The evidence on infarct size was inconsistent and warrants further prospective examination.
P007: Development of provincial recommendations for domestic violence screening in emergency departments and urgent care settings in Alberta
Authors: Arora N. , Arinde F. , Lang E. , McDonald S. , Manji S. , McCracken L. , McLeod L.
Published: May 2019

Introduction: Alberta has one of the highest rates of domestic violence (DV) in the country. Emergency departments (EDs) and urgent care centres (UCCs) are significant points of opportunity to screen for DV and intervene. In Alberta, the Calgary Zone began a universal education and direct inquiry program for DV in EDs and UCCs for patients > = 14 years in 2003. The Calgary model is unique in that (a) it provides universal education in addition to screening and (b) screening is truly universal as it includes all age groups and genders. While considering expanding this model provincially, we engaged in the GRADE Adolopment process, to achieve multi-stakeholder consensus on a provincial approach to DV screening, as herewith described. Methods: Using GRADE, we synthesized and rated the quality of evidence on DV screening and presented it to an expert panel of stakeholders from the community, EDs, and Alberta Health Services. There was moderate certainty evidence that screening improved DV identification in antenatal clinics, maternal health services and EDs. There was no evidence of harm and low certainty evidence of improvement in patient-important outcomes. As per Adolopment, the expert panel reviewed the evidence in the context of: a) values and preferences b) benefits and harms, and c) acceptability, feasibility, and resource implications. Results: The panel came to a unanimous decision to conditionally recommend universal screening, i.e., screening all adults above 14 years of age in EDs and UCCs. By conditional, the panel noted that EDs and UCCs must have support resources in place for patients who screen positive to realize the full benefit of screening and avoid harm. The panel deemed universal screening to be a logistically easier recommendation, compared to training healthcare professionals to screen certain subpopulations or assess for specific symptoms associated with DV. The panel noted that despite absence of evidence that screening would impact patient-important outcomes, there was evidence that effective interventions following a positive screen could positively impact these outcomes. The panel stressed the importance of evidence creation in the context of absence of evidence. Conclusion: A GRADE Adolopment process achieved consensus on provincial expansion of an ED-based DV screening program. Moving forward, we plan to gather evidence on patient-important outcomes and understudied subpopulations (i.e. men and the elderly).
P009: Medical assistance in dying – a survey of Canadian emergency physicians
Authors: Bakewell F.
Published: May 2019

Introduction: There have been 3714 medically assisted deaths recorded in Canada so far, with more than half of those deaths occurring outside the hospital – whether this has had any impact on emergency medicine has not yet been documented. This survey sought to find out Canadian emergency physicians’ (EPs) attitudes and experiences with medical assistance in dying (MAID). Methods: An electronic survey was distributed to CAEP members using a modified Dillman technique. The primary outcome was defined as the proportion of EPs in favour of MAID. Secondary outcomes included experience with suicide in the setting of terminal illness, their experience and opinion on referring patients for MAID from the ED, their experience with complications of MAID, and their response to hypothetical cases of complications from MAID. Nominal variables were analyzed and reported as percentages for each relevant answer. Answers submitted as free-form text were coded into themes by the author and reported based on these themes. Results: There were 303 completed surveys. EPs were largely in support of MAID (80.5%), and would be willing to refer patients for assessment from the ED (83.2%), however fewer (58.3%) knew how to do so. 37.1% of EPs had been asked for a referral for MAID assessment, but only 12.5% had made a referral. While only 1% of EPs reported having seen patients present with complications from MAID (failed IVs in the community), 5.0% had seen patients present with suicide or self-harm attempts after being told they were ineligible for MAID by another provider. Conclusion: This is the first study to examine the impact of MAID on emergency medicine in Canada, and it demonstrates that patients are both requesting referrals through the ED and, in rare cases, requiring medical attention for complications. This has implications for both increasing awareness of MAID referral processes for EPs, as well as for the prevention and treatment of complications of MAID in the community.
P021: Interventions to reduce emergency department door-to-ECG times: a systematic review
Authors: Chhabra S. , Eagles D. , Kwok E. , Perry J.
Published: May 2019

Introduction: We wished to identify emergency department interventions that lead to improvement in door-to-ECG times for adults presenting with symptoms suggestive of acute coronary syndrome (ACS). Methods: Two reviewers searched Medline, Embase, CINAHL and Cochrane CENTRAL from inception to April 2018 for studies in adult emergency departments with an identifiable intervention to reduce median door-to-ECG times when compared to the institution's baseline. Quality was assessed using the ‘Quality Improvement Minimum Quality Criteria Set’ (QI-MQCS) critical appraisal tool. The primary outcome was the absolute median reduction in door-to-ECG times as calculated by the difference between the post-intervention time and pre-intervention time. Results: Two reviewers identified 809 unique articles, yielding 11 before-after quality improvement studies that met eligibility criteria (N = 15,622 patients). The majority of studies (10/11) reported bundled interventions and most (10/11) showed statistical improvement in door-to-ECG times. The most common interventions were: having a dedicated ECG machine and technician in triage (5/11); improved triage education (4/11); improved triage disposition (2/11); and data feedback mechanisms (1/11). Conclusion: There are multiple interventions that show promise for reducing emergency department door-to-ECG times. Effective bundled interventions include having a dedicated ECG technician, triage education and better triage disposition. These changes, bundled together, can help intuitions attain best practice guidelines. Emergency departments must first understand their local context before adopting any single or group of interventions.
P028: Quel est le meilleur moment de départ vers le centre hospitalier pour les patients souffrant d'un arrêt cardiaque extrahospitalier potentiellement éligible à une réanimation par circulation extracorporelle?
Authors: Cournoyer A. , Cossette S. , Daoust R. , Chauny J. , Potter B. , Marquis M. , Morris J. , de Montigny L. , Ross D. , Lamarche Y. , Londei-Leduc L. , Paquet J. , Notebaert É. , Albert M. , Bernard F. , Piette É. , Cavayas Y. , Denault A.
Published: May 2019

Introduction: La réanimation par circulation extracorporelle (R-CEC) permet potentiellement d'améliorer la survie de patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH) réfractaire aux traitements habituels. Cette technique, se pratiquant généralement en centre hospitalier (CH), doit être réalisée le plus précocement possible. Un transport vers le CH en temps opportun est donc nécessaire. Cette étude vise à décrire la durée nécessaire des manœuvres de réanimation préhospitalières afin d'optimiser le moment du départ vers le CH dans le but d'obtenir un maximum de retour de circulation spontanée (RCS) préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients éligibles à une R-CEC selon les critères locaux ont été inclus (<65 ans, rythme initial défibrillable, arrêt témoigné avec réanimation par un témoin). Les patients ayant eu un arrêt devant les paramédics ont été exclus, tout comme ceux avec un RCS avant l'arrivée des services préhospitaliers. Nous avons calculé la sensibilité et la spécificité à différents seuils afin de prédire un RCS préhospitalier et une survie au congé hospitalier. Une courbe ROC a également été construite. Results: Un total de 236 patients (207 hommes et 29 femmes) d'un âge moyen de 52 ans (±10) ont été inclus dans l’étude, parmi lesquels 93 (39%) ont survécu jusqu’à leur congé hospitalier et 136 (58%) ont obtenu un RCS préhospitalier. Le délai moyen avant leur RCS était de 13 minutes (±10). Plus de 50% des survivants avaient eu un RCS moins de 8 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 90% avant 24 minutes. Plus de 50% de tous les RCS survenaient dans les 10 premières minutes de réanimation et plus de 90% dans les 31 premières minutes. La courbe ROC montrait visuellement que le délai avant le RCS maximisant la sensibilité et la spécificité pour prédire la survie chez ces patients était à 22 minutes (Sensibilité = 90%, spécificité = 78%; aire sous la courbe = 0,89 [intervalle de confiance à 95% 0,84-0,93]). Conclusion: Le départ vers le CH pourrait être considéré pour ces patients entre 8 et 24 minutes après l'initiation des manœuvres. Une période de réanimation de 22 minutes semble être le meilleur compromis à cet égard.
P050: Unplanned return visits to the paediatric emergency department: Caregiver and physician perspectives
Authors: Gardner K. , Taylor B.
Published: May 2019

Introduction: Unplanned return visits to the pediatric emergency department contribute to overcrowding and are used as a quality measure. They have not been well characterized in the literature making it difficult to design interventions to reduce unnecessary return visits. The aim of this study was to understand the reasons for return from the caregiver and physician perspective. Methods: This was a cross sectional survey performed on a convenience sample of unplanned return visits within 72 hours at the IWK Health Centre ED between February and October 2016. Exclusion criteria were: planned return visit, admission during the index visit, or triaged as Canadian Triage and Acuity Score (CTAS) 1 on return visit. Caregiver and physician surveys were developed based on themes identified in published literature. The caregiver was approached to complete a survey after triage and the most responsible physician from the return visit was asked to complete a survey immediately after discharge of the patient from their care. Demographic and clinical data were collected from the ED record from the index and return visits. The primary outcome measure was most important reason for return from the caregiver perspective. Results: There were 461 return visits during the study period and 67 caregivers (14.5%) were included in the final analysis. The response rate for the physician survey was 71%. Caregivers and physicians reported that the most important reason for return was a perceived progression of illness requiring reassessment (79.1% and 66.7% respectively). The majority of caregivers had a family physician on record (95%) but a minority attempted to access their family physician (19.4%) or a walk-in clinic (11.9%). Of those who contacted their family physician only 3 (23%) were offered an appointment within 48 hours and of those who did not contact their family physician 21 (38.2%) stated they would not be able to get an appointment in a reasonable amount of time. Despite this 97% would have trusted their family physician to manage their child's illness. Physicians surveyed stated that the return visit was necessary in 64.6% of cases. Conclusion: Caregivers returned to the ED due to a perceived progression of disease. While some cases may have been appropriate for management in a primary care setting, perceived difficulty with timely access was a barrier. Improved caregiver education about the natural history of disease and the urgency of follow up may reduce return ED visits.
P064: A randomized trial comparing telephone tree, text messaging, and instant messaging app for emergency department staff recall for disaster response
Authors: Homier V. , Hamad R. , Larocque J. , Chassé P. , Khalil E. , Franc J.
Published: May 2019

Introduction: A crucial component of a hospital's disaster plan is an efficient staff recall communication method. Many hospitals use a “calling tree” protocol to contact staff members and recall them to work. Alternative staff recall methods have been proposed and explored. Methods: An unannounced, multidisciplinary, randomized emergency department (ED) staff recall drill was conducted at night - when there is the greatest need for back-up personnel and staff is most difficult to reach. The drill was performed on December 14, 2017 at 4:00AM and involved ED staff members from three hospitals which are all part of the McGill University Health Centre (MUHC; Montreal, Quebec, Canada). Three tools were compared: manual phone tree, instant messaging application (IMA), and custom-made hospital Short Message Service (SMS) system. The key outcome measures were proportion of responses at 45 minutes and median response time. Results: One-hundred thirty-two participants were recruited. There were 44 participants in each group after randomization. In the manual phone tree group, 18 (41%) responded within 45 minutes. In the IMA group, 11 participants (25%) responded in the first 45 minutes. In the SMS group, seven participants responded in the first 45 minutes (16%). Manual phone tree was significantly better than SMS with an effect size of 25% (95% confidence interval for effect: 4.6% to 45.0%; P = .018). Conversely, there was no significant difference between manual phone tree and IMA with an effect size of 16% (95% confidence interval for effect: -5.7% to 38.0%; P = .17) There was a statistically significant difference in the median response time between the three groups with the phone tree group presenting the lowest median response time (8.5 minutes; range: 2.0 to 8.5 minutes; P = .000006). Conclusion: Both the phone tree and IMA groups had a significantly higher response rate than the SMS group. There was no significant difference between the proportion of responses at 45 minutes in the phone tree and the IMA arms. This study suggests that an IMA may be a viable alternative to the traditional phone tree method. Limitations of the study include volunteer bias and the fact that there was only one communication drill, which did not allow staff members randomized to the IMA and SMS groups to fully get familiar with the new staff recall methods.