bluuebunny/crossref_metadata_2025 huggingface dataset:
P038: Does the pediatric emergency department have a role in pediatric palliative care?
Authors: Côté A. , Gaucher N. , Payot A.
Published: May 2017

Introduction: Very little is known regarding the emergency department’s (ED) role in the care of paediatric patients with complex chronic and life-limiting illnesses. In fact, the provision of paediatric palliative care (PPC) in the paediatric ED has, of yet, never been explored. This study aims to explore pediatric emergency medicine healthcare professionals’ perspectives regarding their role in PPC and to compare these to other health care professionals’ understandings of the ED’s role in PPC. Methods: Interdisciplinary semi-structured focus groups were held with healthcare providers from pediatric emergency medicine, pediatric palliative care, pediatric complex care and pediatric intensive care. Exploratory open-ended questions introduced naturally occurring discussions and interactions. Data was transcribed in full and analysed using NVivo© software. Data analysis was performed by thematic analysis and theoretical sampling. Results: From January to October 2016, 58 participants were interviewed; most were female nurses and physicians. ED providers seek to maintain continuity of care and uphold pre-established wishes throughout PPC patients’ ED visits by listening and supporting the patient and family, evaluating the clinical situation, communicating with primary care teams and organising rapid admissions to wards. Some ED providers recognized having no choice to provide palliative care approach under certain circumstances despite thinking it might not be part of their culture and role. Each interdisciplinary team demonstrated particular values and cultures, influencing their understandings of the ED’s role in PPC; continuity of care is complicated by these distinct philosophies. Limitations to providing PPC in the ED are related to unsuitable physical environments, lack of uninterrupted time, efficiency expectations, unknown patients, provider lack of knowledge and moral distress. Solutions were directed at improving communication between teams and humanizing care to develop a sensibility to quality PPC in the ED. Conclusion: Although the perspective of pediatric ED’s role in caring for PPC patients is heterogeneous, several barriers to providing high quality emergency PPC can be overcome. Future studies will explore the experiences of PPC families presenting to the ED.
P039: Potential impact on receiving hospital of a prehospital triage system for refractory cardiac arrest: a simulation study
Authors: Cournoyer A. , Notebaert E. , Segal E. , De Montigny L. , Iseppon M. , Cossette S. , Londei-Leduc L. , Lamarche Y. , Morris J. , Piette E. , Daoust R. , Chauny J. , Sokoloff C. , Ross D. , Cavayas Y. , Lafrance D. , Paquet J. , Denault A.
Published: May 2017

Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been used successfully to increase survival in patients suffering from out-of-hospital cardiac arrest (OHCA). However, few OHCA patients can benefit from E-CPR since this procedure is only performed in dedicated centers. Prehospital triage systems have helped decrease mortality from other acute conditions, by directly transporting patients to dedicated centers, often bypassing primary care centers. Our study aimed to quantify the possible impact of a prehospital triage system on the proportion of E-CPR eligible patients transported to E-CPR centers. Methods: We used a registry of adult OHCA collected between 2010 and 2015 from the city of Montréal, Canada. Included patients were adults with non-traumatic witnessed OHCA refractory to 15 minutes of resuscitation. Using this cohort, we created 3 scenarios in which potential E-CPR candidates could be redirected to E-CPR centers. We used strict eligibility criteria in our first pair (e.g. age <60 years old, initial shockable rhythm), intermediate criteria in our second pair (e.g. age <65 years old, at least one shock given) and inclusive criteria in our third pair (e.g. age <70 years old, initial rhythm ≠ asystole). These 3 scenarios were compared to their counterpart in which patients would be transported to the closest hospital. The proportions of patients who would have been transported to an E-CPR centers were compared using McNemar’s test. To obtain a power of 99%, expecting 1% of discordant pairs and using a unilateral alpha of 0.83% (after Bonferroni correction), we needed to include at least 1000 patients. Results: A total of 3136 patients (2054 men and 982 women) with a mean age of 69 years (standard deviation 15) were included. In each simulation, prehospital redirection would have significantly increased the proportion of patients transported to an E-CPR center (pair 1: 1.3% vs 3.8%, p<0.001; pair 2: 2.6% vs 7.3%, p<0.001; pair 3: 7.6% vs 29.8%, p<0.001). Conclusion: In an urban setting, a prehospital triage system could triple the number of patients with refractory OHCA who would have an access to E-CPR. This implies that centers with E-CPR capability should prepare themselves accordingly for such a system to effectively improve survival following OHCA.
P045: Human trafficking awareness, a learning module for improved recognition of victims in the emergency room
Authors: Deutscher J. , Miazga S. , Goez H. , Hillier T. , Lai H.
Published: May 2017

Introduction/Innovation Concept: Estimates suggest that up to eighty-seven percent of human trafficking victims have come into contact with a healthcare provider during their exploitation and yet less than ten percent of emergency medicine (EM) physicians feel confident in identifying a victim. When provided with the relevant tools, medical personnel can aid in the recognition of victims and take the necessary steps in providing appropriate care when they present to the emergency department. Identifying this need for increased awareness in the urgent care setting, a module on human trafficking was implemented into the undergraduate medical education and departmental grand rounds. Methods: After identifying gaps in current medical education regarding screening for victims of human trafficking, a literature review was completed on the topic in medical education and utilized in constructing a list of objectives. These were then reviewed by community organizations that aid victims of trafficking and the Canadian Alliance of Medical Students Against Human Trafficking. Undergraduate medical students completed surveys prior to and following the learning module, in order to evaluate improvement in acquired knowledge. Curriculum, Tool, or Material: A one-hour lecture from ACT Alberta was given to undergraduate medical students as well as to residents and staff in departmental grand rounds. The session met the following objectives: defining human trafficking, recognition of victims, and identification of next steps in providing care. Additionally, an online module from Fraser Health was made available as an additional resource with case studies specific to emergency departments. The surveys consisted of 13 questions evaluating students’ knowledge on human trafficking and its prevalence in emergency medicine. The questions were a combination of a Likert scale, multiple choice, and short answer. There was a large amount of positive feedback from the students and comparison of the surveys showed that their knowledge in identifying victims had significantly improved. Conclusion: Medical students, residents, and staff may come into contact with victims of trafficking in the emergency department and yet less than three percent of emergency physicians have had training on how to recognize a victim. Implementing human trafficking awareness will impact EM medical education by providing victims a greater chance of being recognized and offered help when they present to the emergency room.
P056: Rural versus urban pre-hospital and in-hospital mortality following a traumatic event in Québec, Canada
Authors: Fleet R. , Tounkara F. , Turcotte S. , Ouimet M. , Dupuis G. , Poitras J. , Tanguay A.B. , Fortin J. , Trottier J. , Ouellet J. , Lortie G. , Plant J. , Morris J. , Chauny J. , Lauzier F. , Légaré F.
Published: May 2017

Introduction: Trauma remains the primary cause of death in people under 40 in Québec. Although trauma care has dramatically improved in the last decade, no empirical data on the effectiveness of trauma care in rural Québec are available. This study aims to establish a portrait of trauma and trauma-related mortality in rural versus urban pre-hospital and hospital settings. Methods: Data for all trauma victims treated in the 26 rural hospitals and 32 Level-1 and Level-2 urban trauma centres was obtained from Québec’s trauma registry (2009-2013). Rural hospitals were located in rural small towns (Statistics Canada definition), provided 24/7 physician coverage and admission capabilities. Study population was trauma patients who accessed eligible hospitals. Transferred patients were excluded. Descriptive statistics were used to compare rural with urban trauma case frequency, severity and mortality and descriptive data collected on emergency department (ED) characteristics. Using logistic regression analysis we compared rural to urban in-hospital mortality (pre-admission and during ED stay), adjusting for age, sex, severity (ISS), injury type and mode of transport. Results: Rural hospitals (N=26) received on average 490 000 ED visits per year and urban trauma centres (N=32), 1 550 000. Most rural hospitals had 24/7 coverage and diagnostic equipment e.g. CT scanners (74 %), intensive care units (78 %) and general surgical services (78 %), but little access to other consultants. About 40% of rural hospitals were more than 300 km from a Level-1 or Level-2 trauma centre. Of the 72 699 trauma cases, 4703 (6.5%) were treated in rural and 67 996 (93.5%) in urban hospitals. Rural versus urban case severity was similar: ISS rural: 8.6 (7.1), ISS urban: 7.2 (7.2). Trauma mortality was higher in rural than urban pre-hospital settings: 7.5% vs 2.6%. Reliable pre-hospital times were available for only a third of eligible cases. Rural mortality was significantly higher than urban mortality during ED stays (OR (95% IC): 2.14 (1.61-2.85)) but not after admission (OR (95% IC): 0.87 (0.74-1.02)). Conclusion: Rural hospitals treat equally severe trauma cases as do urban trauma centres but with fewer resources. The higher pre-hospital and in-ED mortality is of grave concern. Longer rural transport times may be a factor. Lack of reliable pre-hospital times precluded further analysis.
P073: Single and dual vs. standard triple agent regimens for HIV post-exposure prophylaxis in the sexual assault victim population
Authors: Kumar T. , Sampsel K. , Stiell I.G.
Published: May 2017

Introduction: Although Tenofovir/Emtricitabine was approved in 2012 as a single-agent regimen for pre-exposure prophylaxis, there have been no studies to our knowledge that demonstrate the efficacy of single and dual agent regimens in post-exposure prophylaxis. Our goal was to compare outcomes of post-exposure prophylaxis with single and dual agent regimens versus triple therapy in victims of sexual assault. Methods: This was a before and after cohort study of patients seen by the Sexual Assault and Partner Abuse Care Program (SAPACP) at the Ottawa Hospital. We reviewed charts of patients seen by the SAPACP from Jan. 1-Dec. 31 2013, when triple therapy was usual care, and Jan. 1-Dec. 31 2015, after the introduction of alternative regimens. Patients who were deemed high risk or who did not get initial treatment at the SAPACP were excluded. Our primary outcome was the number of patients who completed the entire 28-day post-exposure prophylaxis regimen. Secondary objectives were to assess HIV seroconversion rates and patient reported side effects. Results: Six hundred-thirty charts were reviewed, and 429 were included in the study. Baseline characteristics were similar between the two years. We found no significant difference in completion rates of HIV post-exposure prophylaxis between the two cohorts (50.5% vs. 51.6%). However, we did note a decrease in reported side effects in the 2015 cohort (72.2% vs. 17.6%, p<0.0001). In our secondary analysis, we compared all patients in all years who received triple therapy (N=128) versus those who received alternative single or dual agent regimens (N=47). We found that the alternative regimen group had a higher completion rate (66.0% vs. 42.2%; p=0.03), and a dramatic decrease in rate of reported side effects (19.1% vs. 53.9%; p<0.0001). Specifically, we saw decreased reported rates of nausea (12.8% vs. 36.7 %), constipation (0% vs. 7.9%), diarrhea (2.1% vs. 21.1%), mood changes (0% vs. 10.9%), headache (2.1% vs. 16.4%), and fatigue (6.4% vs. 26.6%). There were no HIV seroconversions in either group. Conclusion: Our results suggest that single and dual agent HIV post-exposure prophylaxis regimens are better tolerated by patients and associated with higher rates of completion than triple therapy, and should be considered as stand-alone therapy in the sexual assault victim population.
P075: Constructing entrustment: understanding clinical supervisor dynamics in the oral case presentation
Authors: Landreville J.M. , Cheung W.J. , Hamelin A. , Frank J.R.
Published: May 2017

Introduction: The Oral Case Presentation (OCP) has been described as a unique form of inter-physician communication integral to the practice of medicine and represents the foundation of trainee-supervisor interactions. In recent years, entrustment has been identified as an essential element of trainee supervision and learning. Despite the growing body of knowledge concerning entrustment in medical education, the influence of trust on the educational dynamic surrounding the OCP remains unknown. The objectives of this study were to (1) describe the complex nature of the OCP from the perspective of the supervisor and (2) explore the central role the OCP plays in the dyadic relationship between supervisor and trainee during the delivery of patient care. Methods: Using a constructivist grounded theory approach, semi-structured interviews were conducted from 2015 to 2016 with a purposive sample of attending Emergency Medicine (EM) physicians from the University of Ottawa. Transcripts were reviewed independently by two investigators using line-by-line coding and constant comparative analysis. Emerging concepts were coded and key themes identified through consensus. Theoretical sampling occurred until thematic saturation was reached. Results: Twenty-one attending EM physicians participated in this study (71% male). The mean number of years in practice was 14. The mean percentage of shifts with a trainee assigned was 86%. Factors relating to entrustment were identified as the principal influences on both the content of the OCP and decisions relating to trainee supervision during the OCP process. These factors included the trainee level, the trainee-supervisor relationship, the context and the task. The OCP was also found to play several important roles as supervisors balanced the delivery of patient care and trainee education. These roles were related to communication, teaching and trainee assessment. Conclusion: The OCP represents a core activity within the supervisor-trainee relationship in which trust plays a central role. Clinical supervisors value the OCP as a form of authentic assessment of skills and perceive it to be a key determinant in making entrustment decisions. Future studies designed to evaluate the utility of the OCP as an educational tool should consider entrustment as an essential element.
P076: Calcium, magnesium and phosphorus dosing: impacts and relevance in the emergency department
Authors: Lapointe A. , Berthelot S. , Rousseau F.
Published: May 2017

Introduction: With rising health care costs impairing access to care, the judicious use of diagnostic tests has become a critical issue for most jurisdictions. Among tests regularly performed in the emergency department (ED), calcium (Ca), magnesium (Mg) and phosphorus (P) laboratory testing represents an annual expenditure of more than $4 million for the Québec health care system. We then sought to determine the best indications for ordering these serum levels by identifying patient risk factors predicting abnormal results. Methods: We are conducting a retrospective cohort study in two academic hospitals of Québec City, one providing acute general care and the other providing specialized care to oncologic and nephrologic patients. We included 1000 patients who had serum Ca and/or Mg and/or P levels prescribed by an emergency physician between January 1st 2016 and May 1st 2016. We are collecting demographic (e.g. age) and clinical (e.g. comorbidities) characteristics identified from literature review as potential explanatory variables of an abnormal serum level. Predictive models of a positive test result will be derived from logistic regressions. Results: We have evaluated 143 patients. ED prevalence rates of hypo- and hyper-calcemia (10.1% and 4,3%), hypo- and hyper-magnesemia (13.0% and 7,2%), hypo- and hyper-phosphatemia (9.5% and 13,9%) were similar to those reported in literature. Preliminary bivariate analysis (p<0.05) have shown that, for patients who had serum Ca/Mg/P levels prescribed, one in four complained of weakness, one in five complained of abdominal pain and one in five presented on physical examination an abnormal mental status. Acute and chronic renal failure appears to be a strong predictor of anomalies of any of those electrolytes. Neoplasia, metastasis, hallucinations, bone pain and confusion are more specifically associated with hypercalcemia. Use of corticosteroids is associated with hypocalcemia. Conclusion: Our bivariate analyses have identified potential risk factors of abnormal Ca/Mg/P results. Multivariate logistic regressions will be conducted on the complete planned cohort to further test these preliminary results.
P090: Electronic invitations received from predatory journals and fraudulent conferences: a 6-month young researcher experience
Authors: Mercier E. , Tardif P. , Le Sage N. , Cameron P.
Published: May 2017

Introduction: Predatory publishing is a poorly studied emerging threat to scientists. Junior researchers are preferred targets as they are under academic pressure to publish but face high rejection rates by many medical journals. Methods: All electronic invitations received from predatory publishers and fraudulent conferences were collected over a 6-month period (28th April to 27th October 2016) following the first publication of a junior researcher as a corresponding author. Beall’s list was used to identify predatory publishers and James McCrostie’s criteria to assess if a conference should be considered as predatory. The content of electronic invitations was analyzed and is presented with descriptive statistics. Results: A total of 162 electronic invitations were received during the study period. Seventy-nine were invitations to submit a manuscript. Few invitations disclosed information related to publication fees (9, 11.4%) or mentioned any publication guidelines (21, 26.6%). Most invitations reported accepting all types of manuscripts (73, 92.4%) or emphasized on a deadline to submit (62, 78.4%). These invitations came from 22 different publishers lead by OMICS with 27 invitations (34.2%). Seventy-two invitations to be a speaker (55, 73.4%) or attend (17, 23.6%) a predatory conference were received. These conferences were held most frequently in the USA (25, 34.7%), United Kingdom (15, 20.8%) or United Arab Emirates (8, 11.1%) with only eight mentioning registration fees (11.1%). Forty-one conferences (57.0%) were unrelated to the author’s affiliations or research interests. Finally, five invitations to be a journal’s guest editor, five invitations to become a member of a journal editorial board and one invitation to contribute to the creation of a new journal were received. Conclusion: Young researchers are frequently exposed to predatory publishers and fraudulent conferences. An electronic invitation was received almost daily following the first publication as a corresponding author. Academic institutions worldwide need to acknowledge and educate young researchers of this emerging problem.
P091: Evaluation of pain management in medical transfer of trauma patients by air
Authors: Miles I. , MacDonald R. , Moore S. , Ducharme J. , Vaillancourt C.
Published: May 2017

Introduction: Medical transport services are essential in the regionalization of trauma care. Given the limited number of designated trauma centers, transport times can be prolonged, with patient care managed by paramedics for the duration of their transfer. Pain management is a paramount component, but oligoanalgesia can occur. The primary objective of this study was to evaluate pain management practices during transport of trauma patients by air. Methods: We conducted a 12-month review of ORNGE electronic paramedic records. ORNGE is the exclusive provider of air and land transport in Ontario, Canada. Cases from 1 January 2015 to 31 December 2015 were screened. Patients were identified according to inclusion (≥18 years old requiring transportation to designated trauma center) and exclusion criteria (GCS<14; intubation; accompanied by a nurse or physician). Information was collected in a standardized, piloted data form used by a single trained data extractor. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment according to changes on a 10-point numeric rating scale (NRS), patterns of analgesia administration, and analgesia-related adverse events (AEs). Results were reported as mean, (standard deviation), [range], or percentage. Results: Of 600 potential records, 372 patients met our inclusion criteria with the following characteristics: age 47.0 [19-92] years; 70.4% male; 97.0% blunt injury. Duration of transport was 82.4 (46.3) minutes. Pain was initially assessed in 90.0% of patients. Overall, NRS at baseline was 4.9 (2.8). Of the 62.4% who received analgesia, NRS at baseline was 5.9 (2.5). Fentanyl was most commonly administered (78.5%) at 44.3 [25-60] mcg. NRS after the first dose of analgesia decreased by 1.1 (1.6) points. A total of 73.7% of patients received further analgesia, equal to 2.4 [1-19] additional doses. While 23.4% of patients had no change in NRS after the first dose of analgesia, subsequent doses resulted in no change in NRS in over 65% [65.4-71.3] of patients. A total of 43 AEs (6.7%) were recorded after 638 doses of analgesia, and the most common AE was nausea (39.5%). Conclusion: The majority of patients were assessed for pain. Although the first analgesia administration had minimal effect on NRS, subsequent doses appeared to have even less of an impact. AEs were infrequent.
P093: Sound check: quality in point of care ultrasound in rural and regional Saskatchewan through participatory action research
Authors: Moshynskyy A.I. , Kapusta M. , McGonigle R. , Miller L. , O’Brien J.M. , Thoma B. , Vertue P. , Olszynski P.
Published: May 2017

Introduction: In the rural setting, Point-of-Care Ultrasound (POCUS) can dramatically impact rural acute care. In Saskatchewan, many rural clinicians have undertaken POCUS training, but widespread integration into rural emergency care remains elusive. We aimed to explore of the obstacles limiting adoption and their possible solutions to inform the development of a robust and innovative rural POCUS program in Saskatchewan. Methods: We conducted a mixed methods Participatory Action Research (PAR) study using surveys and focus groups. Our rural co-investigators identified 4 key realms relating to rural POCUS use: equipment, access to training, quality assurance (QA), and research. These guided the design of an online survey sent out to rural clinicians throughout Saskatchewan. Results of the survey informed the development of three approaches (centralized, hub-and-spoke, and decentralized) to training, QA, and research which were discussed at focus group sessions held at Saskatchewan’s Emergency Medicine Annual Conference (Regina, SK. 2016). The focus groups were facilitated by the study investigators. Responses were analyzed using a simple thematic analysis to identify relevant themes and subthemes. Results: 34 rural clinicians responded to the online survey. There was general agreement that POCUS is valuable in rural acute care, training is difficult to access and should be standardized, and that QA and research are desired but impractical in the current environment. 11 rural clinicians attended the focus groups. Analysis of focus groups yielded seven distinct themes/needs: infrastructure needs, peer networks, common standards, both local and regional training opportunities, academic support, access to resources, and culture change. Seventeen sub-themes were identified and noted as having either a positive or negative and direct or indirect effect on the above themes. Broadly speaking, participants supported a distributed “spoke-hub” model where training, research and QA occurs within distributed, regional hubs with support from academic sites. Conclusion: The adoption of POCUS for emergency care in rural Saskatchewan faces significant opportunities and obstacles. There is interest on the part of rural clinicians to overcome these challenges to improve patient care.
CAEP 2016 Academic Symposium: A Writer’s Guide to Key Steps in Producing Quality Education Scholarship
Authors: Chan Teresa M. , Thoma Brent , Hall Andrew Koch , Murnaghan Aleisha , Ting Daniel K. , Hagel Carly , Weersink Kristen , Camorlinga Paola , McEwen Jill , Bhanji Farhan , Sherbino Jonathan
Published: May 2017

A key skill for successful clinician educators is the effective dissemination of scholarly innovations and research. Although there are many ways to disseminate scholarship, the most accepted and rewarded form of educational scholarship is publication in peer-reviewed journals.

This paper provides direction for emergency medicine (EM) educators interested in publishing their scholarship via traditional peer-reviewed avenues. It builds upon four literature reviews that aggregated recommendations for writing and publishing high-quality quantitative and qualitative research, innovations, and reviews. Based on the findings from these literature reviews, the recommendations were prioritized for importance and relevance to novice clinician educators by a broad community of medical educators.

The top items from the expert vetting process were presented to the 2016 Canadian Association of Emergency Physicians (CAEP) Academic Symposium Consensus Conference on Education Scholarship. This community of EM educators identified the highest yield recommendations for junior medical education scholars. This manuscript elaborates upon the top recommendations identified through this consensus-building process.
P110: Acute mountain sickness in the Himalayas: preliminary report
Authors: Sahota I.
Published: May 2017

Introduction: Acute Mountain Sickness (AMS) is a high-altitude medical emergency that requires prompt treatment. If left untreated AMS can progress to high-altitude cerebral edema or pulmonary edema, both of which can be fatal. As the popularity of high altitude trekking increases in the Himalayas we were interested in determining what rates of AMS are on popular routes in this region. Methods: AMS was diagnosed using a standardized Lake Louise Symptom Score (LLSS) where scores 3-5 denoted mild AMS and >5 denoted severe AMS. Forms were distributed to trekkers prior to departure and symptoms scores were determined daily. Data on medical history and patient demographics were also collected. All data are expressed as mean ±SEM. Results: Preliminary results are reported from N=17 (4 female) participants. Mean age was 43.7±3.9y. Most subjects, 68.8%, had trekked above 2500 m in the past. Only 6.25% reported having no knowledge of AMS, with the others having limited or expert knowledge. 25% of subjects had previously suffered from AMS. Most subjects, 82.4%, took prophylactic AMS medication, acetazolamide; at a dose of 250 mg/d. Subjects trekked at a mean altitude of 3650±85 m and ascended to a maximum altitude of 5012±103 m. The mean LLSS was 1.48±0.31 with a maximal LLSS of 4.76±0.75. Within our sample, 70.86% suffered from AMS at some point during their trek. Of those who suffered from AMS, the mean number of days affected was 3.17±0.61, and of those with severe AMS, mean number of days affected was 2.14±0.7. Conclusion: Over 70% of trekkers to the Himalayas experience AMS for an average of 3d, despite the use of prophylactic medication that most participants take. Almost 95% of trekkers have working knowledge of AMS and most have prior experience trekking at high-altitude. Given the dangers of high altitude trekking, pre-departure education for patients, especially those with chronic diseases, alongside prophylactic medication for AMS may help mitigate the risk.
P112: Predicting patient admission from the emergency department using triage administrative data
Authors: Savage D.W. , Weaver B. , Wood D.
Published: May 2017

Introduction: Emergency department (ED) over-crowding and increased wait times are a growing problem. Many interventions have been proposed to decrease patient length of stay and increase patient flow. Early disposition planning is one method to accomplish this goal. In this study we developed statistical models to predict patient admission based on ED administrative data. The objective of this study was to predict patient admission early in the visit with goal of preparation of the acute care bed and other resources. Methods: Retrospective administrative ED data from the Thunder Bay Regional Health Sciences Centre was obtained for the period May 2014 to April 2015. Data were divided into training and testing groups with 80% of data used to train the statistical models. Logistic regression models were developed using administrative variables (i.e., age, sex, mode of arrival, and triage level). Model accuracy was evaluated using sensitivity, specificity, and area under the curve measures. To predict hourly bed requirements, the probability of admission was summed to calculate a pooled bed requirement estimate. The estimated hourly bed requirement was then compared to the historical hourly demand. Results: The logistic regression models had a sensitivity of 23%, specificity of 97%, and an area under the curve of 0.78. Although, admission prediction for a particular individual was satisfactory, the hourly pooled probabilities showed better results. The predicted hourly bed requirements were close to historical demand for beds when compared. Conclusion: I have shown that the number of acute care beds required on an hourly basis can be predicted using triage administrative data. Early admission bed planning would allow resources to be managed more effectively. In addition, during periods of hospital over capacity, managers would be able to prioritize transfers and discharges based on early estimates of ED demand for beds.
P116: A scoping review of factors affecting patient satisfaction with care in North American adult emergency departments
Authors: Sran M.S. , Pyra T. , Chen L. , Holroyd B.R. , McCabe C.
Published: May 2017

Introduction: Patient satisfaction in the emergency department (ED) has been shown to be associated with patient compliance, likelihood to return, and likelihood to recommend the ED. Understanding the factors that affect patient satisfaction in the ED is important but remains poorly understood. This scoping review consolidates the information from the available literature to offer insight into which key factors influence patient satisfaction. Methods: A literature search using initial criteria identified 683 articles. These titles were subjected to inclusion/exclusion criteria and their relevance was independently reviewed by two authors. Consensus was reached on 24 articles to be included, and these were then classified according to study design (class I=observational studies, class II=focus group/qualitative studies, class III=reviews), as well as multiple other factors (ED type, volume of patients, sample size, population, type of study, methodology, study measures, statistical analysis, reliability and conclusions). Using these factors, 25 different ED care attributes were examined in the primary literature, and then narrowed to the 6 most commonly studied factors with 3 categories (wait times, communication/information received in the ED, and interpersonal skills of staff). Results: The impact of wait times (WT) on patient satisfaction in the ED was addressed in 58% of the articles and various studies have found that longer perceived WTs (the length of WTs as reported by patients) are associated with poorer patient satisfaction. Information delivery demonstrated statistically significant associations to both patient satisfaction and the likelihood of a positive recommendation. Interpersonal skills of the staff also demonstrated a strong association with patient satisfaction. Conclusion: The most common factors affecting patient satisfaction in the ED can be categorized under wait times, communication, and the interpersonal skills of the staff. However, the literature in this area is weak, and well-designed comparative studies of the relative importance of each of these factors are necessary to support evidence-based policy making and ultimately improve patient satisfaction.
P119: Health care utilization by patients presenting to the emergency department with mental health complaints
Authors: Thompson C. , McLeod S.L. , Sandre A. , Borgundvaag B.
Published: May 2017

Introduction: Emergency department (ED) visits for mental health and addiction related complaints are common and appear to be increasing. It is believed these patients come to the ED requiring urgent assessment either because they do not have a primary care or psychiatric healthcare provider or access to their provider is not available in a timely fashion. The objective of this study was to describe healthcare utilization in the previous 12 months by patients presenting to the ED with a mental health complaint. Methods: Between April-November 2016, a convenience sample of adult (≥18 years) patients presenting to an academic ED (annual census 65,000) with a mental health and/or addictions complaint were invited to complete a paper-based survey to determine their usage of ten different mental healthcare resources over the previous 12 months. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 134 patients who completed the survey, mean (SD) age was 37.9 (15.7) years and 64 (47.8%) were male. Only 7 (5.2%) patients did not access any mental health resource in the previous 12 months, and the most commonly accessed resource was hospital EDs (102, 76.1%), with 24 (23.5%) of these patients using the ED at least 6 times. Patients also accessed a variety of other mental health resources, with 28 (20.9%) seeing their family physician, 20 (14.9%) seeing their psychiatrist/psychologist, and 61 (45.5%) seeing both in the previous 12 months. Only 6 (5.9%) patients used the ED exclusively for a mental health related complaint. By comparison, respondents accessed other specific mental health resources such as crisis centres (19, 14.2%), helplines (34, 25.4%), and peer-support groups (24, 17.9%) less often. Conclusion: These findings suggest that the ED is the most commonly used mental health resource for this population. However, these patients also frequently access family physicians and psychiatrists/psychologists, with community resources such as crisis centres, helplines, and peer-support being used less often. This suggests that lack of timely access to other mental health resources may be the primary motivation for accessing the ED.
P121: Understanding health equity: a pilot project to collect socio-demographic information on emergency department patients at registration
Authors: Vaillancourt S. , McGowan M. , Semprun C. , Hannam P. , Bandiera G. , Ovens H.J.
Published: May 2017

Introduction: There is strong evidence that socio-economic factors such as income, housing and ethnicity are linked to health outcome disparities for emergency department (ED) patients. However, lack of real-time patient data has limited our ability to identify, understand and address health disparities. During a 14-week period, we assessed the feasibility and acceptability of the systematic collection of patient-level equity data in a busy tertiary care urban ED. Methods: We assessed feasibility by directly observing impact on registration time, percentage of patients on which data was collected, and ambulance patient data collection. We also assessed acceptability to patients, registration staff and clinicians through structured interviews of patients systematically sampled, focus group and surveys of registration staff and survey of clinicians. Results: Over the course of the study, equity data was collected on 2017 patients. Capture rate peaked in week 7 with 51% of eligible patients offered the equity questions and 30% answering. Average patient registration time increased from 215 seconds to 345 seconds (60%). Data collection with ambulance patients did not appear feasible. Patients (n=30) reported being comfortable with most questions except income (47% comfortable). 93% believed it could improve health services. However, a small number of patients voiced concern that the data could result in discrimination. Registration staff required sustained support and engagement, but some continued to feel uncomfortable with offering the questionnaire to some patients. Conclusion: Large scale collection of equity data is feasible but requires additional resources and sustained staff and patient support. Patient participation rate is likely to remain relatively low and is likely to underestimate disadvantaged groups. Data collection at multiple points within an institution may improve capture rate.
P130: Learning through simulation-a debriefing faculty development course
Authors: Woolfrey K.G.
Published: May 2017

Introduction/Innovation Concept: Introduction of a new simulation program including structured debriefing represents a substantial challenge. Debriefing performance is critical for facilitating learning in simulation. However, many faculty members are unfamiliar with the debriefing process. Faculty receives no training for conducting impactful and safe debriefs. Consequently, they are uncomfortable and often disengaged. We designed, implemented, and evaluated an innovative faculty-debriefing curriculum. Do professional development efforts in simulation debriefing teaching result in improved engagement in simulation teaching by faculty, increased comfort with simulation teaching, and an acceptance of a critical thinking framework for simulation teaching? Methods: We designed the curriculum to include the flipped classroom and deliberate practice models. Participants (n=26; 42% of Emergency Medicine Faculty) were pre-circulated course materials, and then attended a full day course to introduce the simulation setting, the equipment, and two practice scenarios. Each scenario was followed by a group debrief. Twenty-one participants (80.7% response rate) completed pre and post course surveys; we analyzed the data using descriptive statistics. Curriculum, Tool, or Material: Results: Descriptive findings from a pre-course and post-course survey were conducted. Prior to participating in the innovation, 75% had participated in simulation teaching at Western, but only 30% of this faculty being comfortable with this teaching format. 65% of participants had no formal simulation training and 95% had no training in debriefing. Results of the post-course survey revealed 100% satisfaction with the flipped classroom model; and 48% and 52% were extremely likely and very likely to attend future faculty development courses respectively. 100% of participants felt comfortable in participating in debriefing post simulation teaching with 50% feeling comfortable to do this independently without a co-debriefer. 100% of participants felt that the critical thinking framework that was presented in the course for a debriefing model would translate into their clinical teaching in the future. Conclusion: Faculty development has a critical role to play in promoting academic excellence and innovation. Faculty development programs must respond to the changes in medical education. This education project integrated a unique model of learning for faculty, engaged faculty, and increased their comfort level for teaching in simulated setting and utilizing structured debriefing.
P131: Risk factors for recurrent emergency department visits for hyperglycemia in patients with diabetes mellitus
Authors: Yan J.W. , Gushulak K. , Columbus M. , Van Aarsen K. , Hamelin A. , Wells G.A. , Stiell I.G.
Published: May 2017

Introduction: Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation. Methods: We conducted a one-year health records review of patients ≥18 years presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Trained research personnel collected data on patient characteristics and determined if patients had an unplanned recurrent ED visit for hyperglycemia within 30 days of their initial presentation. Multivariate logistic regression models using generalized estimating equations to account for patients with multiple visits determined predictor variables independently associated with recurrent ED visits for hyperglycemia within 30 days. Results: There were 833 ED visits for hyperglycemia in the one-year period. 54.6% were male and mean (SD) age was 48.8 (19.5). Of all visitors, 156 (18.7%) had a recurrent ED visit for hyperglycemia within 30 days. Factors independently associated with recurrent hyperglycemia visits included a previous hyperglycemia visit in the past month (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.1-5.8), age <25 years (OR 2.6, 95% CI 1.5-4.7), glucose >20 mmol/L (OR 2.2, 95% CI 1.3-3.7), having a family physician (OR 2.2, 95% CI 1.0-4.6), and being on insulin (OR 1.9, 95% CI 1.1-3.1). Having a systolic blood pressure between 90-150 mmHg (OR 0.53, 95% CI 0.30-0.93) and heart rate >110 bpm (OR 0.41, 95% CI 0.23-0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit. Conclusion: This unique ED-based study reports five risk factors and two protective factors associated with recurrent ED visits for hyperglycemia within 30 days in patients with diabetes. These risk factors should be considered by clinicians when making management, prognostic, and disposition decisions for diabetic patients who present with hyperglycemia.
CAEP 2016 Academic Symposium on Education Scholarship: Training our Future Clinician Educators in Emergency Medicine
Authors: Woods Robert A. , Artz Jennifer D. , Carrière Benoit , Field Simon , Huffman James , Dong Sandy L. , Bhanji Farhan , Yiu Stella , Smith Sheila , Mengual Rose , Hicks Chris , Frank Jason
Published: May 2017

Objective

To develop consensus recommendations for training future clinician educators (CEs) in emergency medicine (EM).

Methods

A panel of EM education leaders was assembled from across Canada and met regularly by teleconference over the course of 1 year. Recommendations for CE training were drafted based on the panel’s experience, a literature review, and a survey of current and past EM education leaders in Canada. Feedback was sought from attendees at the Canadian Association of Emergency Physicians (CAEP) annual academic symposium. Recommendations were distributed to the society’s Academic Section for further feedback and updated by a consensus of the expert panel.

Results

Recommendations were categorized for one of three audiences: 1) Future CEs; 2) Academic departments and divisions (AD&D) that support training to fulfill their education leadership goals; and 3) The CAEP Academic Section. Advanced medical education training is recommended for any emergency physician or resident who pursues an education leadership role. Individuals should seek out mentorship in making decisions about career opportunities and training options. AD&D should regularly perform a needs assessment of their future CE needs and identify and encourage potential individuals who fulfill education leadership roles. AD&D should develop training opportunities at their institution, provide support to complete this training, and advocate for the recognition of education scholarship in their institutional promotions process. The CAEP Academic Section should support mentorship of future CEs on a national scale.

Conclusion

These recommendations serve as a framework for training and supporting the next generation of Canadian EM medical educators.
PL04: Initial serum lactate predicts deterioration in emergency department patients with sepsis
Authors: Fernando S.M. , Barnaby D.P. , Herry C.L. , Seely A.J.
Published: May 2017

Introduction: Early Emergency Department (ED) identification of septic patients at risk of subsequent deterioration is necessary in order to optimize disposition. High-risk patients admitted directly from the ED to the ICU have better outcomes than those admitted to the floor first. Initial ED serum lactate level has been associated with 28-day mortality in admitted patients, but there is little evidence on its use in predicting short-term deterioration. Furthermore, it is unclear whether the addition of respiratory rate (RR) to lactate would create a stronger predictive model of deterioration than either alone. Methods: Prospective cohort study of ED patients (age ≥18) screened and treated for sepsis (defined as physician suspicion of infection and 2 or more of the SIRS criteria). Lactate and vital signs were obtained within 2 hours of ED arrival. Main outcome was deterioration (defined as any of the following: death; ICU admission >24 hours; Intubation; Vasoactive medications for >1 hour; or Non-invasive positive pressure ventilation for >1 hour) within 72 hours. Patients meeting an endpoint within 1 hour of arrival were excluded. Discharged patients were contacted at 72 hours to ensure that they had not met the endpoint or presented to another institution. Results: 985 patients presenting to either of two urban high-volume EDs were enrolled, of whom 84 (8.5%) met the primary outcome. Initial serum lactate ≥ 4.0 had a specificity of 97.4% (95% CI, 94.1-100%), but a sensitivity of 27.4% (95% CI, 17-8-36.9%) for predicting deterioration. Of patients with a lactate ≥ 4.0, 4 (8.7%) were discharged home, and did not reach an endpoint at 72 hours. Lactate <2.0 had a sensitivity of 95.5% (95% CI: 93.4-97.1%) and specificity of 84.5% (95% CI: 80.4-88.6%) for ruling out 72-hour deterioration. Of patients with a lactate <2.0, 224 (56.1%) were discharged home. Combining lactate with RR (AUC: 0.72, 95% CI: 0.66-0.79) did not yield better predictive capability than lactate alone (AUC: 0.70, 95% CI: 0.64-0.76). Conclusion: Initial ED lactate is predictive of deterioration within 72 hours in patients with sepsis. The combination of lactate and RR was not more predictive of deterioration than lactate alone. This suggests that serum lactate has a role in predicting deterioration in patients with sepsis, and has utility in determining disposition.