bluuebunny/crossref_metadata_2025 huggingface dataset:
MP034: What is the diagnostic accuracy of Canadian emergency physicians and cardiologists interpreting potential acute ST-elevation myocardial infarction (STEMI) electrocardiograms?
Authors: Barbic D. , Vadeanu C. , Grunau B.E. , Ramanathan K. , Scheuermeyer F.X.
Published: June 2016

Introduction: The accurate interpretation of potential ST-segment elevations on electrocardiograms (ECGs) to diagnose acute myocardial infarction (MI) is a critical competency for emergency physicians (EPs) and cardiologists. There is conflicting evidence on the diagnostic accuracy of EPs and cardiologists interpreting potential STEMI ECGs. Methods: We conducted a web-based assessment of the diagnostic accuracy of potential STEMI ECGs of Canadian EPs and cardiologists. They were identified using the membership lists of the Canadian Association of Emergency Physicians and the academic departments of cardiology at Canadian medical schools. When provided with 20 ECGs of confirmed STEMI patients, EPs and cardiologists were asked to provide a binary Yes/No answer to the question, “In a patient with ischemic chest pain, does this ECG represent a STEMI?” EPs and cardiologists were blinded to the correct answers while completing the web-based assessment. Descriptive statistics were used to described frequencies and counts. Analysis using Rasch Measurement Theory was used to explore the relationship between correct interpretation of ECGs and predictive variables such as age, years in practice or type of practice. Results: Two hundred and fifty EPs and 30 cardiologists (n=280) responded to our survey (total response rate 25%). Average years in practice were 12.5 for EPs (SD 10.6; median 10) and 14.6 for cardiologists (SD 10.6; median 11); 52% of EPs and 93% of cardiologists practiced in an academic setting. Seven of the cardiologists were interventionalists, while 47.6% of EPs and 97% of cardiologists practiced at hospitals with 24-hour catheterization capability. The diagnostic accuracy of EPs for identifying STEMI ECGs was 75% (SD 15%); cardiologists’ accuracy was 76% (SD 15.5%). The ability to correctly interpret the ECGs was independent of age, years in practice, or type of practice (community vs academic). Conclusion: EPs and cardiologists display similar diagnostic accuracy for interpreting STEMI ECGs, regardless of age, years in practice or type of practice. The findings of our study suggest the need for focused ECG education for both EPs and cardiologists.
P002: Ten patients, one ventilator: how to best allocate critical care resources during mass disaster
Authors: Acton C. , McGowan M. , Gray S.H.
Published: June 2016

Introduction: Any large-scale disaster may place a hospital system in a precarious position. Planning is fundamental to facilitate an equitable process for allocating scarce critical care resources, yet there is a paucity of literature guiding protocol development, and few Canadian hospitals have done this planning. We performed a scoping review of the available literature, and used this data to develop a hospital-wide policy to guide critical care resource allocation as part of the hospital emergency management planning process. Methods: A primary search of MEDLINE (1946-2015), EMBASE (1980-2015), Disaster Lit (2002-2010) and Pubmed focusing on a priori criteria was completed. A secondary search of the grey literature served to increase sensitivity and rigor. Two independent reviewers manually reviewed the citations, and selected eligible abstracts for full-text. Qualitative thematic analysis was undertaken of the selected articles. The results then informed the development of a hospital-wide policy and protocol to guide critical care resource allocation. Results: The search identified 832 citations; 134 papers were reviewed and 11 selected for qualitative analysis. All included papers were expert opinion and reviews. All suggested that an ethical framework be used; eight discussed this in detail. Ten recommended allocating a triage team to implement the protocol. Nine papers recommended specific resource allocation protocols with inclusion/exclusion criteria, physiologic scores, and reassessment at varying time intervals (12-120 hours). Conclusion: Effective planning, prior to a disaster, is critical to saving as many lives as possible. Based on our scoping review, we have developed a hospital-wide protocol that incorporates ethical principles and clear inclusion and exclusion criteria, to help avoid inequity and promote transparent decision-making. Next steps include a public consultation process and review, prior to implementation testing and educational roll-out.
P003: Do all clavicle fractures in children need to be managed by orthopaedic surgeons?
Authors: Adamich J.S. , Camp M. , Howard A.
Published: June 2016

Introduction: Although many uncomplicated pediatric fractures do not require routine long-term follow-up with an orthopedic surgeon, practitioners with limited experience dealing with pediatrics fractures will often defer to a strategy of frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the healthcare system. Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of clavicle fractures was performed. Results: Three hundred and forty patients (227 males, 113 females) with an average age of 8.1 (range 0.1-17.8) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.1 (±1.3). The mean number of radiology department appointments was 1.8 (±1.3) where patients received a mean number of 4.2 (±3.0) radiographs. Complications were minimal; 2 refractures in our series and no known cases of non-union. All patients achieved clinical and radiographic union and returned to sport after fracture healing. Conclusion: Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary-care physician, then routine clinical or radiographic follow up is unnecessary. Our paediatric clavicle fracture pathway will reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients’ families without jeopardizing patient outcomes.
P004: What happens to cognitive load during trauma skill training using computer based video instructions?
Authors: Addison R.N. , Rohr L.E. , Dubrowski A.
Published: June 2016

Introduction: In the clinical settings, emergency physicians are faced with situations that require multitasking such as interacting with other team members, documentation and utilization of computer resources whiles ensuring competency on a particular trauma skill. The purpose of this study was to assess the effect of multitasking on cognitive load when learning a common trauma skill. Methods: Sixteen students who had no previous experience with the one-handed square knot were randomly assigned to one of the two groups: practice and non-practice groups. A pre-recorded instructional video of a one-hand knot tying was presented to all participants. Next, the practice group completed a single session of 10 trials of the one-hand knot tying using a benchtop simulator, while the non-practice group did not. All returned a week later for a transfer task on a different simulator. On trials 1, 4, 7,10 and during the transfer performance the participants performed under dual task conditions, where they were asked to focus on the knot-tying task, but also to react as fast as possible to the illumination of an incandescent light bulb by pressing a foot pedal. Subjective ratings of mental effort, and reaction time to the visual stimulus were used as indices of cognitive load. Results: A repeated measure ANOVA showed a significant effect of dual task on subjective measure of mental effort (F(4, 28) = 10.35, p = .001, ω = .60) and reaction time (F(4, 28) = 7.93, p = .001, ω = .53), with plots indicating cognitive load plateaued by the 7th trial. Conclusion: These findings highlights the number of trials necessary to attain a level of proficiency in a basic trauma skill such as the one-hand knot tying, ease the level of cognitive load and possibly enhance transfer to more challenging tasks.
P009: Violence against health care professionals in Karachi: results from a mixed methods study
Authors: Arif S. , Baig L.A.
Published: June 2016

Introduction: The right to live is the supreme human right and according to Article 3 of the Universal declaration of human rights everyone has a right to life, liberty and security. In Karachi, Pakistan huge numbers of health care professionals (HCP) have been subjected to violence inclusive of money extortion, kidnapping, mental & physical torture, murders etc. A recent study from Karachi’s four major hospitals reported that 72.5% of HCP have experienced abuse (verbal and physical) in the past 12 months. The goal of this study was to develop strategies for preventing violence against health care after collecting baseline data. The objectives of the study were to: Identify the magnitude, threshold and impact of violence against HCPs. Methods: This was a mixed methods study design with a QUAN-QUAL approach. Structured questionnaire was used after pilot testing and filled by the surveyors. Focus group discussion and In-depth interviews were conducted with HCPs, NGOs, Law enforcement agencies, ambulance services, hospital administrators and LHW programs. Frequencies and proportions were compared for different cadres of HCPs for the quantitative data analysis. Thematic content analysis with inductive and deductive reasoning was used for analysing qualitative data. Results: Data on 822 HCPs revealed that 33% had faced violence and 49 % had experienced it, 89% was verbal and 43% was physical abuse, 2% had died and 22% were injured. Ambulance services and physicians were the most common victims of violence. The main reasons were grouped as institutional, behavioral (victims and perpetrators) and general situation of the city. There is high acceptance of violence among HCPs and lack of training in dealing with it was the most common reason given. Sequlae included effects on victim, family, institution and the reporting agencies. The final paper will have complete details on the baseline and the recommendations proposed by the stakeholders. Conclusion: Violence faced by HCP’s is a multifactorial complex issue. There is a dire need to design interventions which can help in addressing the behavioral, Institutional and sociopolitical factors promoting violence among HCP’s. The interventions based on recommendations by the respondents have been developed and implementation has started as a pilot in the city of Karachi.
P010: Use of the emergency department by refugees under the Interim Federal Health Program
Authors: Bakewell F. , Addleman S. , Thiruganasambandamoorthy V.
Published: June 2016

Introduction: In June 2012, the federal government made cuts to the Interim Federal Health (IFH) Program that reduced or eliminated health insurance for refugee claimants in Canada. The purpose of this study was to examine the effect of the cuts on emergency department (ED) use among patients claiming IFH benefits. Methods: We conducted a health records review at two tertiary care EDs in Ottawa. We reviewed all ED visits wherein an IFH claim was made at triage, for 18 months before and 18 months after the changes to the program on June 30, 2012 (2011-2013). Claims made before and after the cuts were compared in terms of basic demographics, chief presenting complaints, acuity, diagnosis, presence of primary care, and financial status of the claim. Results: There were a total of 612 IFH claims made in the ED from 2011-2013. The demographic characteristics, acuity of presentation and discharge diagnosis were similar during both the before and after periods. Overall, 28.6% fewer claims were made under the IFH program after the cuts. Of the claims made, significantly more were rejected after the cuts than before (13.7% after vs. 3.9% before, p<0.05). The majority (75.0%) of rejected claims have not been paid by patients. Fewer patients after the cuts indicated that they had a family physician (20.4% after vs. 30% before, p<0.05) yet a higher proportion of these patients were still advised to follow up with their family doctor during the after period (67.2% after vs. 41.8% before, p<0.05). Conclusion: A higher proportion of both rejected and subsequently unpaid claims after the IFH cuts in June 2012 represents a potential barrier to emergency medical care, as well as a new financial burden to be shouldered by patients and hospitals. A reduction in IFH claims in the ED and a reduction in the number of patients with access to a family physician also suggests inadequate care for this population. Yet, the lack of primary care was not reflected in the follow-up advice offered by ED physicians to patients.
P018: A prospective diagnostic support tool for the differentiation of abdominal pain in the adult emergency department population
Authors: Butler M.B. , Kenney T. , Gu H. , Carter A. , Ling S.
Published: June 2016

Introduction: The chaotic environment of the emergency department has a deleterious effect on clinical judgement. The diagnosis of abdominal pathology is difficult to differentiate. There are also many diagnoses that could be considered abdominal in nature, exacerbating the task of diagnosing these patients. We propose a novel machine-learning method, Hierarchical Structured Models (HSMs), to provide an adjunct to clinician judgement, that provides a ranking of the probabilities of a patient having each of 39 abdominal pathologies, using only variables at the triage stage of emergency department care, and compare its performance to several machine-learning methods. Methods: This was a retrospective analysis of 25,861 patients that presented with one of 39 ICD-9 abdominal pathologies. 90% of the data was used to build and fine-tune the model, and 10% was used for testing. Predictors included age, gender, triage vitals and presenting complaint. All variables were solely collected from the Emergency Department Information System (EDIS). A decision tree structure was built using hierarchical clustering algorithms, and then a support vector machine (SVM) was fit at each node. To optimize the parameters for each node, a grid-search method was used to maximize ten-fold classification accuracy. The output of the decision tree was the probability of a particular presentation having each of the 39 diagnoses. This output was translated to a ranking of the relative likelihood of each of the diagnoses as a suggestion system for the treating physician. The accuracy of the system on the test set was compared to conventional machine-learning methods: pair-wise SVMs, gradient boosted models (GBM), neural networks (NN) and k-nearest neighbours (KNN). Results: The HSM ranked the correct diagnosis first 51.0% of the time, and ranked the correct diagnosis within the top three ranks 67.6% of the time. The most accurate model was GBMs (52.3%), and the least was neural networks (50.4%). Conclusion: The HSM approach using only variables available electronically at triage successfully ranked the correct diagnosis 51.0% of the time, and within the top three 67.6% of the time. Future research will focus on the inclusion of clinically lab results and radiology reports that are available electronically to improve HSM accuracy, and supplement physician diagnosis.
P023: Code Resus - using a quality improvement approach to improve health care provider response during resuscitations
Authors: Chartier L.B. , Hansen S. , Lim D. , Yi S. , McGovern B. , Davies D. , Beane K. , Harada N. , Xie E.
Published: June 2016

Introduction: In order to achieve the best possible outcomes for patients requiring resuscitation (PRRs) in the emergency department (ED), health care providers (HCPs) must provide an efficient, multi-disciplinary and coordinated response. A quality improvement (QI) project was undertaken to improve HCP response to PRRs at two tertiary care hospital EDs in Toronto. Methods: We conducted a before-and-after mixed-method survey to evaluate the perception of the adequacy of HCP response and clarity of HCP role when responding to PRRs. The results were compared using the Chi-square test. Qualitative responses to the first survey were also used to inform the development of the QI project. Through interviews of key stakeholders and with continuous input from front-line ED HCPs, a multi-disciplinary team modified the ED resuscitation protocol. This included standardized pre-hospital communication form with paramedics, ED-wide overhead announcement of ‘Code Resus’, dedicated HCPs assigned to respond to PRRs, and specific duties assigned to each responder. Change initiatives were reinforced through education and posters in the ED. Six months after implementation, a second survey was conducted to evaluate the sustained effects of the intervention. Results: Baseline measures indicated that 16 of 52 (30.8%) nurses surveyed believed their role was often or always apparent to themselves and others when they attended to a PRR (on a 5-point rating scale). This proportion increased to 35 of 55 (63.6%) nurses in the post-implementation survey (p < 0.001). Regarding adequacy of the number of HCPs responding to PRRs, 17 of 39 (43.6%) physicians and 23 of 53 (43.4%) nurses surveyed thought the appropriate number of HCPs responded to PRRs; the remainder thought that there were too few or too many HCPs. In the post-implementation survey, 34 of 41 (82.9%) physicians (p < 0.001) and 36 of 56 (64.3%) nurses (p = 0.029) surveyed felt that the appropriate number of HCPs attended to PRRs. Conclusion: Using a quality improvement approach, we identified and quantified perceived deficiencies in HCP response to PRRs in the ED. Through feedback-based modifications of the ED resuscitation protocol and by engaging HCP stakeholders, change initiatives were implemented to improve HCP response. As a result, this project achieved significant and sustained improvements in HCPs’ perceived response to PRRs.
P029: A novel use of a point-of-view camera for teaching lateral canthotomy and cantholysis to emergency physician trainees
Authors: Cote S.L. , Punja K. , Gooi P. , Gooi A. , Warrian K.
Published: June 2016

Introduction / Innovation Concept: Orbital compartment syndrome (OCS) is a vision threatening ocular emergency that occurs when there is a sudden rise in orbital pressure resulting in damage to intraocular structures. Lateral canthotomy and cantholysis (LCC) is a simple procedure used to decompress the orbit. Emergency physicians should be comfortable evaluating and diagnosing OCS, and performing a LCC to decrease the risk of vision loss in the event that consultation and intervention by an ophthalmologist is not possible in a timely manner. Developing this skill is challenging as this procedure is seldom performed, therefore resources need to be available. Current training videos are an excellent learning tool but are limited by several factors, such as not capturing from the perspective of the physician performing the procedure. Point-of-view (POV) cameras show the physician’s perspective, which is more conducive to training as it mimics the experience for trainees. We report our novel technique of recording a LCC using a head-mounted POV camera as a resource for emergency physician trainees in learning this procedure. Methods: We used a head mounted POV GoPro Hero 4 Silver camera (GoPro, San Mateo, CA, U.S.A.) with a modified 5.4mm f/2.5 aftermarket lens with a 60° field of view (Peau Productions Inc, San Diego, CA, U.S.A.). This lens was pre-focused to a working distance of 17 inches, set to 1080P on narrow recording at 48 frames per second, and had spot metering and the low light functions turned on. The camera functions were controlled remotely by an assistant with the use of GoPro App on a tablet computer to ensure proper framing of the camera. Curriculum, Tool, or Material: Our novel use of a POV camera for recording LCC is an efficient, cost effective tool useful for medical education at an academic institution as well as a valuable resource for emergency room clinicians. The POV recording system can be a training device in an emergency setting for performing a LCC or other procedures that emergency physicians may seldom encounter. Conclusion: Point-of-view cameras have great potential in assisting the education at the post-graduate level within residency training programs. Video recording from the physician’s perspective simulates the experience for trainees and could leave them feeling more confident in their ability to perform the procedure.
P033: Engaging Indigenous patients in addressing cultural safety in an emergency department: a pilot initiative
Authors: Dell E.M. , Firestone M. , Smylie J. , Whitebird W. , Vaillancourt S.
Published: June 2016

Introduction: Cultural safety is integral to good clinical care, particularly for Indigenous patients. However, it remains poorly defined in emergency department care (ED). Practitioners at an urban Canadian ED serving a significant Indigenous population sought to engage with the community to define areas for improvement in culturally safe emergency department care. Methods: A participatory action approach was used. A Steering Committee was created, including emergency clinicians and Indigenous health researchers. The Committee collaborated with a local Indigenous health study (Our Health Counts) to aid recruitment. Relevant Indigenous community organizations were identified and engaged via email and personal visits. Recruitment posters were placed in common areas at community sites and the ED. Convenience and snowball sampling was used - potential participants called an ED research coordinator and inclusion criteria were confirmed (self identify as Indigenous, >18 years old, ED visit within the past year). Eligible participants were invited to attend a focus group facilitated by an Aboriginal Elder. Results: 31 individuals called to enroll for a total of 4 potential focus groups. 1 was successfully held: 5 participants were confirmed, 2 attended. Many recruitment challenges were identified, including difficulty maintaining contact/follow-up with a transient population, poster dissemination before recruitment start date, non-Indigenous patients attracted by compensation, and potential participant safety concerns regarding non-Indigenous contact point. Conclusion: Our initiative highlights challenges in engaging vulnerable populations in a large city. Focus groups may be logistically too challenging for this transient population. Other real-time data collection methods, such as phone interviews or surveys may be promising. An Indigenous contact point would likely improve perceived safety. The lack of socio-demographic data collection makes identifying potential participants challenging.
P039: What are the frequencies of interventions performed by paramedics during seizure calls?
Authors: Eby D. , Robson J. , Columbus M.
Published: June 2016

Introduction: Paramedics frequently attend out-of-hospital seizure patients. They administer oxygen, check blood glucose levels and if within scope of practice, start IVs and administer benzodiazepines. Little is know about how frequently these procedures are performed. The objective of this study was to determine the frequency of procedures performed by paramedics (Advanced Care (ACP), Primary Care IV (PCP-IV) and Primary Care non-IV (PCP)) attending seizure patients in a regional paramedic base hospital program. Methods: Retrospective analysis of a secondary database of ambulance call reports (ACRs) (January 01-December 31, 2014). All 2854 ACRs with paramedic determined primary / final problem codes of “seizure” were identified from total calls performed by 8 municipal paramedic services (MPSs), covering an urban and rural population of 1.4 million. MPSs used iMedic electronic ACRs. A 10% sample, generated using a random number table, was analyzed. ACRs were manually searched and data extracted onto spreadsheets. Findings were summarized using descriptive statistics. Results: 285 calls were analyzed; (adult 72.7%, paediatric (age <18) 27.3%). Paramedics witnessed seizures in 8.1% of all calls they attended; (paediatric 7.8%). The blood sugar was checked in 87.9% of adult calls; (ACP 88.7%, PCP-IV 89%, PCP 77.8%) and in 70.5% of paediatric calls; (ACP 72.0%, PCP-IV 63.3%, PCP 70.5%). Oxygen was administered in 80.7% of adult calls; (ACP 85.9%, PCP-IV 78.0%, PCP 80.7%) and 83.3% of paediatric calls; (ACP 92.0%, PCP-IV 80.1%, PCP 82.4%). IVs were started by paramedics (if in scope of practice) in 28.0% of adult calls; (ACP 47.9%, PCP-IV 16.1%) and 6.6% of paediatric calls; (ACP 8.0%, PCP-IV 5.6%) Midazolam was administered in 10.4% of ACP attended calls and in 91.0% of the calls were they witnessed seizures. Transport occurred in 93.2% of adult calls and 100% of paediatric calls. Conclusion: ACPs were more likely to perform procedures on seizure patients than PCPs or PC-IVs. Children were much less likely to have procedures performed on them - blood sugar checks, and IV starts - but more likely receive oxygen and be transported. These findings have training implications.
P043: Education innovation: a postgraduate emergency medicine musculoskeletal medicine curriculum
Authors: Foran A.S.
Published: June 2016

Introduction / Innovation Concept: Musculoskeletal medicine (MSKM) complaints account for a significant portion of emergency room visits. Furthermore, MSKM diagnostic and management skills are poorly taught in undergraduate medicine and emergency medicine (EM). Here, we successfully developed an MSKM curriculum resulting in objectively improved resident acumen. Methods: Curriculum development was achieved by surveying local EM residents on their perceived MSKM deficits, and effective MSK teaching strategies. A literature search was also completed identifying MSKM teaching shortcomings. Finally, orthopaedic surgeons were asked which clinical entities they thought should be emphasized in our curriculum. Curriculum, Tool, or Material: A case-based MSKM curriculum was created. Cases emphasized commonly occurring emergency department presentations, topics that EM practitioners self-identified as requiring further teaching, commonly missed problems at first presentation, and high-risk cases if mismanaged. Curriculum implementation consisted of three, half-day, workshops. Workshops included didactic lectures, MSKM physical exam practice, and MSKM cases. MSKM cases required resident history taking and physical exam practice, radiography interpretation, and management plan formulation. Objective assessments of resident MSKM knowledge and skill were given to the learners before and after the workshops. Survey questions were grouped into 3 categories: MSK assessment, investigation, and management. Questions were scored on a 5-point Likert scale, ranging from “not at all confident” to “very confident”. A Wilcoxon Signed Rank Test indicated statistically significant improvement in learner confidence within all three domains after the first workshop (n=19 learners; assessment: p<0.001, investigation: p<0.001, management: p<0.001), and after the second workshop (n=24 learners; assessment: p<0.001, investigation: p<0.001, management: p<0.001). Conclusion: We successfully incorporated MSKM teaching into our academic curriculum based on previously identified weaknesses, resulting in improved resident MSKM case management. Further MSKM teaching sessions and evaluations to facilitate knowledge and skill maintenance are currently under development.
P051: Validation of the Sainte-Justine head trauma pathway for children younger than 2 years of age
Authors: Gravel J. , Spénard S. , Beaudin M. , Gouin S.
Published: June 2016

Introduction: The PECARN head CT scan rule helps to identify children at risk of clinically important Traumatic Brain Injury (ciTBI) but many children fall in a grey zone while applying the rule (observation vs. CT scan). The C-3PO rule identifies children at risk of skull fracture. The Ste-Justine Head Trauma pathway comprises both rules for the management of all children younger than two years who suffered a head trauma. The primary objective of this study was to measure the capacity of the Ste-Justine Head Trauma pathway to identify children with ciTBI. Methods: This was a retrospective study of all children younger than two years old who visited a university affiliated pediatric emergency department (ED) for a head trauma between Sept. 2013 and Aug. 2015. Participants were all patients admitted for a head trauma and a randomly selected sample of 5% of non-admitted patients. Independent variables of the algorithm were recorded for each patient. The primary outcome was the presence of a ciTBI defined by any of the following secondary to TBI: death, neurosurgery, intubation of more than 24 hours or hospitalization for more than one night. Participants were identified using the computerized database of the ED and all charts were reviewed using a standardized report form. The primary analysis was the proportion of children with ciTBI accurately identified using the pathway. A secondary analysis was to compare the performance of the pathway in comparison to the PECARN rule alone. Results: During the study period a total of 2,258 children were seen in the ED for head trauma. The charts of all hospitalized (n=100) and a sample (n= 101) of non-hospitalized children were reviewed. A ciTBI was found in 26 participants (3 neurosurgical interventions, 4 intubated and 26 admitted > one night). Among them, 18 were classified at high risk, 7 at moderate risk and 1 at low risk according to the clinical pathway. Using the PECARN rule alone would have classified 17 at high risk, 5 at moderate risk and 4 at low risk. Using the pathway to the entire population would yield the following risk of cTBI: High-risk: 25%; moderate risk: 1%; low risk < 0.1%. Conclusion: The Ste-Justine Head Trauma pathway effectively identifies children younger than two years at risk of ciTBI following head trauma while triaging effectively children at low risk. The pathway is more sensitive than the PECARN rule to identify children at risk of ciTBI.
P054: Development of a hospital-wide program for simulation-based training in trauma care and management
Authors: Green R. , Minor S. , Hartlen K. , Erdogan M.
Published: June 2016

Introduction: The Queen Elizabeth II Health Sciences Centre (QEII HSC) is a Level I trauma center that provides tertiary care services to the province of Nova Scotia (pop. 940,592) and quaternary care services to Atlantic Canada (population > 2.4 million). The objective of this study was to describe and evaluate the development of an inter-professional hospital-wide trauma simulation that was performed at the QEII HSC in June of 2015. Methods: The simulation was performed in the dedicated trauma resuscitation bay in the emergency department of the trauma centre using SimMan equipment. The scenario involved a 35-year-old male pedestrian versus car at approximately 70 km. The patient required immediate resuscitation and transfer to the operating room for an emergency laparotomy. Evaluation of the simulation was through video feedback, time stamping, piloting of resident Trauma Team Activation evaluation, observation for latent safety issues, and participant feedback. Trauma team members were unaware of simulation prior to arrival. Results: Feedback received from simulation participants indicated that this exercise was incredibly “real” for them. Using the usual emergency department patient registration proved difficult in this simulation exercise, both for activation of the massive transfusion protocol and transfer of the patient to the operating room. Latent safety issues identified included a lack of communication with the operating room and unavailability of some resuscitation equipment. Debriefing after the event was felt to be important by all participants of the simulation. Having evaluators dedicated to observing specific aspects of the simulation would facilitate these exercises. Patient care was not interrupted in the emergency department or the operating room. Conclusion: The in situ simulation was a valuable experience for the trauma program, stakeholders, and all participants. Based on this trial simulation, additional simulations will be held within our trauma program. Further research is required to validate long-term retention of skills and knowledge, and to evaluate the impact of simulation training on staff performance and trauma patient outcomes.
P055: State of the evidence for emergency medical services (EMS) provision of palliative care: an analysis of appraised research from the Canadian Prehospital Evidence-based Practice (PEP) Project
Authors: Carter A. , Greene J. , Cook J. , Goldstein J. , Jensen J. , Derosa A. , Swain J. , Fidgen D. , Muise A. , Cain E.
Published: June 2016

Introduction: Patients who require end of life (EoL)/palliative care occasionally need assistance from paramedics. This review evaluated the evidence for paramedic-delivered EoL/palliative care interventions. Methods: The Canadian Prehospital Evidence-based Practice (PEP) Project methodology was used. A PubMed search was conducted, using Medical Subject headings and title/abstract key words. Titles and abstracts were reviewed for relevance. Studies were not required to be EMS based but must have focused on interventions available to EMS personnel. Included full text studies were scored by trained primary appraisers on a three-point Level of Evidence (LOE) scale (high = 1, moderate = 2 and low = 3) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing). Studies were categorized by clinical condition (n=5) and by intervention (n=25), and plotted on 3×3 (DOE × LOE) tables. The study primary outcome and setting were determined. Results: The search returned 3255 articles; 86 were selected for abstract review; with 30 full text articles ultimately included. Intervention recommendations were: LOE 1-supportive (n=3, 12%), 2-supportive (n=2, 8%), 3-supportive (n=2, 8%), 1-neutral (n=2, 8%), 2-neutral (n=2, 8%), 3-neutral (n=4, 16%). No primary studies were identified for 10 (40%) interventions. Conditions with 1-supportive studies were: ‘breathlessness’ and ‘analgesia’. ‘Secretions’ condition had no relevant evidence. Interventions with 1-supportive evidence were: Haldol for agitation (n=1), fentanyl and morphine for analgesia (n=3 and n=1), narcotics for breathlessness (n=1). No intervention had opposing evidence. Primary outcomes were more commonly related to symptom relief (n=26, 87%), safety (n=3, 10%), or tolerability (n=1, 3%). Only one included study was conducted in the EMS setting. Conclusion: Evidence for interventions used by paramedics in the treatment of patients requiring EoL/palliative care was identified, as were evidence gaps. Little research was conducted in the EMS setting, and most interventions had few studies. These PEP findings highlight topics requiring high quality EMS research specific to EoL/palliative care to inform this growing aspect of paramedic practice.
P056: The state of the evidence for emergency medical services (EMS) care of blunt spinal trauma: an analysis of appraised research from the Canadian Prehospital Evidence-based Practice (PEP) Project
Authors: Carter A. , Greene J. , Cook J. , Goldstein J. , Jensen J.
Published: June 2016

Introduction: The Canadian Prehospital Evidence-based Practice (PEP) project is an online, freely accessible, continuously updated EMS evidence repository. The summary of research evidence for EMS interventions used to care for blunt spinal trauma is described. Methods: PubMed was systematically searched. One author reviewed titles and abstracts for relevance. Included studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing results). Second party appraisal was conducted for included studies. Interventions were plotted on a 3x3 table (DOE × LOE) for the spinal injury condition based on appraisal scores. The primary outcome was identified for each study and categorized. Results: Seventy-seven studies were included. Evidence for adult and paediatric blunt spinal trauma interventions was: supportive-high quality (n=1, 7 %), supportive-moderate quality (n=3, 21.4%), supportive-low quality (n=1, 7%), neutral-high quality (n=1, 7%), neutral-moderate quality (n=5, 35.7%), neutral-low quality (n=1, 7%), opposing-high quality (n=0, 0%), opposing-moderate quality (n=0, 0%), opposing-low quality (n=1, 7%). One (7%) intervention had no evidence. Interventions with supportive evidence were: steroids, cervical-spine clearance, scoop stretcher, self-extrication and “leaving helmet in place”. The evidence weakly opposed use of short extrication devices. Leading study primary outcomes were spinal motion, diagnostic accuracy, and pressure/discomfort. Conclusion: EMS blunt spinal trauma interventions are informed by moderate quality supportive and neutral evidence. Future research should focus on high quality studies filling identified evidence gaps using patient-oriented outcomes to best inform EMS care of blunt spinal injury.
P057: Performance of a national simulation-based resuscitation OSCE for emergency medicine trainees
Authors: Hagel C. , Hall A.K. , Klinger D. , McNeil G. , Dagnone D.
Published: June 2016

Introduction: The use of high-fidelity simulation is emerging as an effective method for competency-based assessment in postgraduate medical education. We have previously reported the development of the Queen’s Simulation Assessment Tool (QSAT), for use in simulation-based Objective Structured Clinical Examinations (OSCEs) for Emergency Medicine (EM) trainees. We aimed to demonstrate the feasibility and present an argument for the validity of a simulation-based OSCE utilizing the QSAT with EM residents from multiple Canadian training sites. Methods: EM post-graduate trainees (PGY 2-5) from 9 Canadian EM training programs participated in an 8-station simulation-based resuscitation OSCE at Queen’s University in Kingston, ON. Each station was scored by a single trained rater from a group of 9 expert Canadian EM physicians. Raters utilized a station-specific QSAT and provided an Entrustment Score. A post-examination questionnaire was administered to the trainees to quantify perceived realism, comfort and educational impact. Statistical analyses included analysis of variance to measure the discriminatory capabilities and a generalizability study to examine the sources of variability in the scores. Results: EM postgraduate trainees (N=36) participated in the study. Discriminatory validity was strong, with senior trainees (PGY4-5) outperforming junior trainees (PGY2-3) in 6 of 8 scenarios and in aggregated QSAT and Entrustment Scores across all 8 stations (p<0.01). Generalizability studies found the largest sources of random variability was due to the trainee by station interaction and the error term, with a G coefficient of 0.84. Resident trainees reported reasonable comfort being assessed in the simulation environment (3.6/5), indicated significant perceived realism (4.1/5), and found the OSCE valuable to their learning (4.8/5). Conclusion: Overall, this study demonstrates that a large-scale simulation-based EM resuscitation OSCE is feasible, and an argument has been presented for the validity of such an examination. The incorporation of simulation or a simulation-based OSCE in the national certification process in EM may help to satisfy the increased demand for competency-based assessment required by the Royal College of Physicians & Surgeons of Canada’s Competency by Design transition.
P069: Gestalt assessment of online educational resources is unreliable and inconsistent
Authors: Krishnan K. , Trueger S. , Thoma B. , Lin M. , Chan T.M.
Published: June 2016

Introduction: The use of free open access medicine, particularly open educational resources (OERs), by medical educators and learners continues to increase. As OERs, especially blogs and podcasts, rise in popularity, their ease of dissemination raises concerns about their quality. While critical appraisal of primary research and journal articles is formally taught, no training exists for the assessment of OERs. Thus, the ability of educators and learners to effectively assess the quality of OERs using gestalt alone has been questioned. Our goal is to determine whether gestalt is sufficient for emergency medicine learners (EM) and physicians to consistently rate and reliably recommend OERs to their colleagues. We hypothesized that EM physicians and learners would differ substantively in their assessment of the same resources. Methods: Participants included 31 EM learners and 23 EM attending physicians from Canada and the U.S. A modified Dillman technique was used to administer 4 survey blocks of 10 blog posts per subject between April and August, 2015. Participants were asked whether they would recommend each OER to 1) a learner or 2) an attending physician. The ratings reliability was assessed using single measures intraclass correlations and their correlations amongst the groups were assessed using Spearman’s rho. Family-wise adjustments were made for multiple comparisons using the Bonferroni technique. Results: Learners demonstrated poor reliability when recommending resources for other learners (ICC= 0.21, 95% CI 0.13-0.39) and attending physicians (ICC = 0.16, 95% CI=0.09-0.30). Similarly, attendings had poor reliability when recommending resources for learners (ICC= 0.27, 95% CI 0.18-0.41) and other attendings (ICC=0.22, 95% CI 0.14-0.35). Learners and attendings demonstrated moderate consistency between them when recommending resources for learners (rs=0.494, p<.01) and attendings (rs=0.491, p<.01). Conclusion: Using a gestalt-based rating system is neither reliable nor consistent when recommending OERs to learners and attending physicians. Learners’ gestalt ratings for recommending resources for other learners and attendings were especially unreliable. Our findings suggests the need for structured rating systems to rate OERs.
P078: Handover education in Canadian adult and pediatric emergency medicine residencies: a national survey and needs assessment
Authors: Lee P. , Rigby I. , McPherson S.J.
Published: June 2016

Introduction: Emergency department handover is a high-risk period for patient safety. A recent study showed a decreased rate of preventable adverse events and errors after implementation of a resident hand-off bundle on pediatric inpatient wards. In a 2013 survey by the Canadian Associations of Internes and Residents, only 11% of residents in any discipline stated they received a formal teaching session on handover. Recently, the CanMEDS 2015 Physician Competency Framework has added safe and skillful transfer of patient care as a new proficiency within the collaborator role. We hypothesize that significant variation exists in the current delivery and evaluation of handover education in Canadian EM residencies. Methods: We conducted a descriptive, cross-sectional survey of Canadian residents enrolled in the three main training streams of Emergency Medicine (FRCP CCFP-EM, PEM). The primary outcome was to determine which educational modalities are used to teach and assess handover proficiency. Secondarily, we described current sign-over practices and perceived competency at patient handover. Results: 130 residents completed the survey (73% FRCP, 19% CCFP-EM, 8% PEM). 6% of residents were aware of handover proficiency objectives within their curriculum, while 15% acknowledged formal evaluation in this area. 98% of respondents were taught handover by observation of staff or residents on shift, while 55% had direct teaching on the job. Less than 10% of respondents received formal sessions in didactic lecture, small group or simulation formats. Evaluation of handover skills occurred primarily by on shift observation (100% of respondents), while 3% of residents had received assessment through simulation. Local centre handover practices were variable; less than half of residents used mnemonic tools, written or electronic adjuncts. Conclusion: Canadian EM residents receive variable and sparse formal training and assessment on emergency department handover. The majority of training occurs by on shift observation and few trainees receive instruction on objective tools or explicit patient care standards. There exists potential for further development of standardized objectives, utilization of other educational modalities and formal assessments to better prepare residents to conduct safer patient handoffs.
P083: Why do older adults in assisted living facilities use the emergency department: are all these visits necessary?
Authors: Losier E. , McCollum A. , Jarrett P. , McCloskey R. , Nicholson P. , Howlett M.
Published: June 2016

Introduction: Special Care Home (SCH) residents require supervision for activities of daily living but not regular nursing care. Emergency Department (ED) use by seniors in SCHs is poorly studied. A recent study in Nova Scotia found seniors represented over 20% of ED visits. We studied SCH resident ED visits in a community with a population of 30,000 aged over 65 years and with 785 SCH beds, to define reasons for ED visits to a tertiary ED, and if these could be avoided. Methods: We performed a retrospective chart review of SCH residents’ visits to an ED (SCH-ED) which has 56,000 total ED (TED) visits over one year. Reasons for visit, admission data, and avoidability were collected. A geriatrician and ED physician independently reviewed visits. Initial disagreement on avoidability (27%) was adjudicated through case discussion. Results: Demographic data revealed 344 ED visits by 111 SCH residents over one year; 37% of visits resulted in admission. 13.9% of residents visited the ED on at least one occasion (average 3.1 visits); mean age 78.4 years; female 66.7%; ambulance arrival 91.0%. The three most common chief complaints were shortness of breath, weakness and abdominal pain. Most SCH-ED visits were Canadian Triage and Acuity Scale (CTAS) Level 3 (63.4%, TED 53.3%). Of CTAS Level 3 visits, 35.3% were admitted (TED 12.9%). SCH-ED visits were avoidable in 40.6% of cases. Gastrointestinal (18%), pain (16.5%), falls, functional decline or injury (14%) and respiratory (12%) were the most common avoidable diagnostic groups, accounting for 57% of total SCH visits. Conclusion: ED visits by SCH residents demonstrated increased acuity and admission rates with a high number of repeat visits. Of all SCH-ED visits, 40% were potentially avoidable. Further study may determine if improved community services reduces ED visits or hospital admission. Gastrointestinal, respiratory, falls and pain diagnoses may be important areas of focus.