bluuebunny/crossref_metadata_2025 huggingface dataset:
MP27: Costs of emergency syncope care in Canada
Authors: Kim S. , Cook O. , Yau L. , Mukarram M.A. , Arcot K. , Ishimwe A. , Thavorn K. , Taljaard M. , Sivilotti M. , Rowe B.H. , Thiruganasambandamoorthy V.
Published: May 2017

Introduction: Syncope is a common emergency department (ED) presentation and constitutes 1% of all ED visits, approximately 160,000 visits annually across Canada. Lack of standardized syncope care has economic and cost implications. Currently, emergency medical services (EMS) is over utilized, variations in ED management exist and a substantial proportion (46.5%) are hospitalized for cardiac monitoring. Our previous studies have proposed ways to reduce health care utilization through development of EMS clinical decision tool, ED risk scores and remote cardiac monitoring. We sought to: 1) Estimate costs associated with syncope care in the pre-hospital, ED and inpatient settings; and 2) Determine potential cost savings if the proposed alternate strategies were adopted. Methods: A prospective cohort study was conducted in five Canadian EDs from 2010-2014. We enrolled adult (≥16 years) syncope patients and excluded those with prolonged loss of consciousness, mental status changes, seizure, significant trauma, or alcohol/illicit drug abuse. Demographics, medical history, mode of arrival, EMS time points, reasons for hospitalization, ED and inpatient length of stay, final ED diagnosis and any serious adverse event within 30 days of index visit were collected. Descriptive and inferential statistics were used. Results: Out of 4,064 patients enrolled, 67.3% were transported to the ED by EMS and the average cost per event was $262.78 (range at study sites: $156.43-$553.03). The average cost per ED visit was $267.98 (range: $174.66-$374.95). 12.9% of the patients were admitted and the average of cost per admission was $9,886.15 (range: $9,715.23-$10,277.98). Syncope is associated with an estimated total annual cost of $257 million. In Canada, we estimate that diverting low-risk patients will save $5 million in the pre-hospital setting and $15 million in the ED annually, and implementing a remote cardiac monitoring strategy will save $50 million annually. Conclusion: It is estimated that the proposed strategies will save $70 million annually. This is likely an underestimation as cost savings due to reduction in investigations related to diversion of ED patients, reduction in ED length of stay and hospitalization are unaccounted. Adoption of similar strategies will likely lead to significantly higher cost savings in countries with higher resource utilization for syncope management.
MP30: Validation of the 4AT questionnaire in the emergency department
Authors: Gagné A. , Voyer P. , Boucher V. , Pelletier M. , Gouin E. , Berthelot S. , Daoust R. , Laguë A. , Bédard C. , Émond M.
Published: May 2017

Introduction: Delirium is a very prevalent cognitive impairment in elderly inpatients, but it often goes undetected, especially in the emergency department (ED). The tools currently available to screen or diagnose patients at risk of delirium are very time-consuming and are impossible to systematically perform in the ED environment. For this reason, short tests are necessary to screen for delirium in this fast-paced setting. The objective of this study was to evaluate the performance of the French version of the Rapid Assessment Test for Delirium (4AT) for the detection of delirium and cognitive impairment in older patients. The 4AT takes less than 2 minutes to administer, which is a great advantage on the others tests. Methods: The study was conducted in four emergency departments across the province of Québec. Participants were independent or semi-independent patients aged 65 and older, admitted to hospital and who had an 8-hour exposure to the ED. The Telephone Interview for Cognitive Status (TICS) was administered at the initial interview and the Confusion Assessment Method (CAM) as well as the 4AT were administered to patients twice a day during their ED or hospital stay. The 4AT’s sensitivity and specificity were compared to that of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Results: 324 patients were included in the study, with a mean age of 76 years old. Among the recruited participants, 21 (6.5%) had a prevalent delirium according to the CAM, and 30 (10.2%) had an incident delirium. According to the 4AT, 48 patients (14.9%) had cognitive impairment and 81 (25.2%) had a prevalent delirium. According to the TICS, 87 patients (29.2%) have cognitive impairment. The 4AT has a sensitivity of 68,4% (IC 95% : 47,5-89,3) and a specificity of 73.2% (IC 95% : 67,8-78,7) for delirium, and a sensitivity of 50% (IC 95% : 35,9-64,1) and a specificity of 87,0% (IC 95% : 81,2-92) for cognitive impairment. Conclusion: The French Version of the 4AT could be a fast and reliable screening tool for delirium and cognitive impairment in ED. Further research is necessary for its validation in the ED.
MP33: A systematic review of the psychometric properties and diagnostic performance of instruments to identify mental health and substance use problems among children in the emergency department
Authors: Kirkland S.W. , Soleimani A. , Gokiert R. , Newton A.S.
Published: May 2017

Introduction: The objective of this systematic review was to investigate the psychometric properties and diagnostic performance of instruments used in the emergency department to identify pediatric mental health and substance use problems. Methods: A search of seven electronic databases and the grey literature was conducted. Studies assessing any instrument to identify and or diagnose mental illness, emotional or behavioural problems, or substance use disorders in pediatric patients with presentations for mental health or substance use issues were considered eligible for inclusion. Two independent reviewers judged the relevance and study quality of the studies. A descriptive analysis of the outcomes was reported. Results: From 4832 references, 14 studies were included. Eighteen instruments were evaluated for identifying suicide risk, alcohol use disorders, mood disorders, and ED decision-making. The HEADS-ED has good inter-rater reliability (r=0.785) for identifying general mental health problems and modest evidence for ruling out patients requiring hospital admission (positive likelihood ratio, LR+=6.30). The internal consistency varied for tools to screen for suicide risk (α=0.46-0.97); no tools have both high sensitivity and high specificity. The Ask Suicide-Screening Questionnaire (ASQ) is highly sensitive (98%) and provides strong evidence to rule out risk (negative likelihood ratio, LR−=0.04). Among tools to screen for alcohol use disorders, a two-item tool based on DSM-IV criteria was found to be the most accurate in identifying patients with a disorder (area under the curve: 0.89), and has modest evidence to rule in and rule out risk (LR+=8.80, LR−=0.13). Conclusion: Reliable, valid, and accurate instruments are available for use with pediatric mental health ED visits. Based on available evidence, emergency care clinicians are recommended to use the HEADS-ED to rule in ED admission, ASQ to rule out suicide risk, and DSM-IV two-item tool to rule in/rule out alcohol use disorders.
MP34: Assessment of pain management during transport of intubated patients in a prehospital setting
Authors: Zia A. , MacDonald R. , Moore S. , Ducharme J. , Vaillancourt C.
Published: May 2017

Introduction: While methods have been developed to assess pain and provide analgesia to hospitalized intubated patients, little is known about current EMS practices in providing similar care during air and land medical transports. Therefore, we sought to determine if opioid analgesia is provided to intubated patients during transportation in out-of-hospital setting. Methods: We conducted a health record review examining electronic records of intubated patients transported by Ornge in 2015. Ornge is the exclusive provider of air and land transport of critically ill patients in Ontario, Canada with over 18,000 transports per year. We identified cases using Ornge’s database and selected intubated patients meeting inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was frequency of administration and dose adequacy of an opioid analgesic. Secondary outcomes included: choice of analgesics used (fentanyl, hydromorphone or morphine), adverse events, and impact of age, sex, or reason for transfer on pain management. We present descriptive statistics. Results: Our strategy identified 500 potential cases, of which 448 met our inclusion criteria. Among those 448 patients, 154 (34.4%) were females, 328 (73.4%) received analgesia and 211 (64.3%) received more than one dose during transport (median frequency of 2 doses, IQR=1 to 3). The average transport time was 148 minutes and repeated dosing (>1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.6%) and most commonly used dose was 50 micrograms (51.8%). Adverse events occurred in 8 (2.5%) patients with 5 patients having new hypotension (MAP <65 mm Hg). There was no significant difference in administration of analgesia based on patient’s age or sex (68.8% of females and 75.3% of male patients received analgesia). Interestingly, 30.8% of patients repatriated to originating-hospital received analgesia compared to 72.3% of patients receiving analgesia for all other reasons for transfers. Conclusion: More than 73% of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex or reason for transfer other than home repatriation.
P001: Do all toddler’s fractures need to be managed by orthopaedic surgeons?
Authors: Adamich J.S. , Camp M.
Published: May 2017

Introduction: There is increasing evidence that emergency room physicians or primary care physicians can definitively manage many uncomplicated paediatric fractures without orthopaedic follow-up. This strategy leads to a reduction in radiation exposure and decreased costs to patient families and the healthcare system without impacting patient outcomes. The aim of this study was to determine whether patients who sustained a toddler’s fracture of the tibia required orthopaedic surgeon follow-up. Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of toddlers’ fractures between Jan 2009 and Dec 2014 was performed. Results: 186 patients (115 males, 72 females) with an average age of 2.00 (range 0.2-3.9) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.00 (±1.0). The mean number of radiology department appointments was 2.76 (±1.1) where patients received a mean number of 5.86 (±2.6) radiographs. Complications were minimal and no patient developed a non-union nor re-fractured. All patients achieved clinical and radiographic union. To date, no patient has returned to clinic or undergone surgery for concerns regarding leg length inequality or malalignment. Conclusion: Our series supports reduced clinical follow-up of patients with a toddler’s fracture of the tibia. If the diagnosis can be made on the initial radiographs, emergency room physicians or primary care providers can definitively manage these patients with appropriate immobilization that can be removed by the parents between 3-4 weeks after the injury. A fracture clinic follow-up is only necessary if the diagnosis cannot be made on the initial radiographs. Our toddler’s fracture pathway will reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients’ families without jeopardizing patient outcomes.
P003: Emergency department quality assurance sepsis project: why are more people dying in southwestern Ontario?
Authors: Aguanno A. , Van Aarsen K. , Columbus M.
Published: May 2017

Introduction: London Health Sciences Centre (LHSC) includes two academic, urban hospitals in London, Canada. The hospital-standardized mortality ratio (HSMR) is consistently higher than provincial and national averages. Unpublished data reveals that sepsis contributes the largest number of statistically unexpected deaths to LHSC’s HSMR calculation. Factors contributing to in-hospital sepsis mortality are hypothesized to include demography, emergency department (ED) flow or sepsis treatment. Methods: Retrospective chart review of patients aged >=18 years, presenting to an LHSC ED between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis (ICD-10 diagnostic codes A4xx and R65). Data were abstracted from electronic health records. Regional, provincial and national data was retrieved from CIHI and Statistics Canada. Results: Median age and sex in London and across Canada are similar (48.2 years vs 48.9 years; 48% male vs 49% male). Baseline prevalences of diabetes, hypertension, COPD and mood disorders were similar in the Local Health Integration Network and Ontario (6% vs 7%, 19% vs 19%, 3% vs 4%, and 10% vs 8%). Median “Physician Initial Assessment,” (PIA) times for sepsis patients at LHSC were faster than median Canadian PIA times for CTAS I and II patients (CTAS I: 7 min vs 11 min, CTAS II: 34 min vs 54 min), and slower for CTAS III-V patients (CTAS III: 98 min vs 79 min, CTAS IV: 99 min vs 66 min, CTAS V: 132 min vs 53 min). Median ED length of stay for admitted, high acuity (CTAS I-III) patients was 6 h at LHSC versus 10 h across Canada.Median [IQR] time to intravenous fluid resuscitation was 60.5 min [29.8-101.2] for septic shock patients and 77.0 min [36.0-127.0] for expired patients. Median [IQR] time to antibiotics was 130 min [73.0-229.0] for sepsis patients, 106 min [60.0-189.0] for severe sepsis patients, and 82 min [42.2-142] for septic shock patients. Conclusion: Excess sepsis-related mortality at LHSC is not convincingly related to patient demographics or ED flow. Gains may be made by improving time to antibiotics and IV fluids.
P004: Hair cannabinoid concentrations in hyperemesis cannabis: a case-control study
Authors: Albert K. , Hookey L.C. , Ruberto A.J. , Gareri J. , Sivilotti M.
Published: May 2017

Introduction: Emergency physicians increasingly encounter young patients with protracted, forceful hyperemesis associated with heavy cannabis use, previously termed “cyclic vomiting.” The national discourse on liberalization of cannabis has largely ignored this poorly understood condition. We wondered to what degree hyperemesis cannabis is an idiosyncratic reaction, like motion sickness or migraine, versus a more predictable dose-response effect of heavy, prolonged use. Methods: As part of a larger case-control study using structured interviews, we measured cannabinoid concentrations in scalp hair of both cases and controls. Cases were required to have an emergency visit for vomiting, 2+ episodes of severe vomiting in the previous year, history of near-daily use of cannabis for 6+ months, positive urine Δ9-tetrahydrocannabinol (THC) and age 16-55 years; exclusion criteria were chronic opioid use, synthetic cannabinoid use, or established alternative diagnosis. Age- and sex-matched chronic cannabis-using controls without vomiting were identified via social referral primarily from the cases themselves. Scalp hair was analyzed for THC, cannabinol (CBN), cannabidiol (CBD) and 11-nor-9-carboxy-THC (THC-COOH) by LC-MS/MS (limit of quantification ~15 pg/mg hair; accuracy <5%) in an independent laboratory blinded to subject classification. Results: We obtained satisfactory hair and urine samples from 18 cases (median [IQR] age 27 [20,31] years; 12 male) and 13 controls. THC and CBN concentrations were higher in cases than controls (THC 240 [120,820] vs 99 [73, 290] pg/mg; CBN 63 [33, 260] vs 15 [negative, 76] pg/mg; each P<0.05). CBD and THC-COOH were often unquantifiable to undetectable in both cases and controls. Conclusion: Hyperemesis cannabis patients have substantially higher hair cannabinoid concentrations than their peers without vomiting, although there is some overlap. The association cannot demonstrate a direct dose-response with THC--confounding (e.g. other cannabinoids, external smoke deposition), altered metabolism and reverse causation (e.g. seeking temporary symptom relief by using more cannabis) could also yield a positive association. Nevertheless, these findings support counselling patients with hyperemesis to reduce or discontinue using cannabis. They also support national regulatory initiatives including education, labelling, and progressive taxation based on potency intended to discourage excessive use.
P007: A comparative analysis of qSOFA, SIRS and Early Warning Scores Criteria to identify sepsis in the prehospital setting
Authors: AlQahtani S. , Menzies P. , Bigham B. , Welsford M.
Published: May 2017

Introduction: Early recognition of sepsis is key in delivering timely life-saving interventions. The role of paramedics in recognition of these patients is understudied. It is not known if the usual prehospital information gathered is sufficient for severe sepsis recognition. We sought to: 1) evaluate the paramedic medical records (PMRs) of severe sepsis patients to describe epidemiologic characteristics; 2) determine which severe sepsis recognition and prediction scores are routinely captured by paramedics; and 3) determine how these scores perform in the prehospital setting. Methods: We performed a retrospective review of patients ≥18 years who met the definition of severe sepsis in one of two urban Emergency Departments (ED) and had arrived by ambulance over an eighteen-month period. PMRs were evaluated for demographic, physiologic and clinical variables. The information was entered into a database, which auto-filled a tool that determined SIRS criteria, shock index, prehospital critical illness score, NEWS, MEWS, HEWS, MEDS and qSOFA. Descriptive statistics were calculated. Results: We enrolled 298 eligible sepsis patients: male 50.3%, mean age 73 years, and mean prehospital transportation time 30 minutes. Hospital mortality was 37.5%. PMRs captured initial: respiratory rate 88.6%, heart rate 90%, systolic blood pressure 83.2%, oxygen saturation 59%, temperature 18.7%, and Glasgow Coma Scale 89%. Although complete MEWS and HEWS data capture rate was <17%, 98% and 68% patients met the cut-point defining “critically-unwell” (MEWS ≥3) and “trigger score” (HEWS ≥5), respectively. The qSOFA criteria were completely captured in 82% of patients; however, it was positive in only 36%. It performed similarly to SIRS, which was positive in only 34% of patients. The other scores were interim in having complete data captured and performance for sepsis recognition. Conclusion: Patients transported by ambulance with severe sepsis have high mortality. Despite the variable rate of data capture, PMRs include sufficient data points to recognize prehospital severe sepsis. A validated screening tool that can be applied by paramedics is still lacking. qSOFA does not appear to be sensitive enough to be used as a prehospital screening tool for deadly sepsis, however, MEWS or HEWS may be appropriate to evaluate in a large prospective study.
P010: Code Silver: Lessons learned from the design and implementation of Active Shooter Simulation In-Situ Training (ASSIST)
Authors: Argintaru N. , Petrosoniak A. , Hicks C. , White K. , McGowan M. , Gray S.H.
Published: May 2017

Introduction: Hospital shootings are rare events that pose extreme and immediate risk to staff, patients and visitors. In 2015, the Ontario Hospital Association mandated all hospitals devise an armed assailant Code Silver protocol, an alert issued to mitigate risk and manage casualties. We describe the design and implementation of ASSIST (Active Shooter Simulation In-Situ Training), an institutional, full-scale hybrid simulation exercise to test hospital-wide response and readiness for an active shooter event, and identify latent safety threats (LSTs) related to the high-stakes alert and transport of internal trauma patients. Methods: A hospital-wide in-situ simulation was conducted at a Level 1 trauma centre in downtown Toronto. The two-hour exercise tested a draft Code Silver policy created by the hospital’s disaster planning committee, to identify missing elements and challenges with protocol implementation. The scenario consisted of a shooting during a hospital meeting with three casualties: a manikin with life-threatening head and abdomen gunshot wounds (GSWs), a standardized patient (SP) with hypotension from an abdominal GSW, and a second SP with minor injuries and significant psychological distress. The exercise piloted the use of a novel emergency department (ED)-based medical exfiltration team to transport internal victims to the trauma bay. The on-call trauma team provided medical care. Ethnographic observation of response by municipal police, hospital security, logistics and medical personnel was completed. LSTs were evaluated and categorized using video framework analysis. Feasibility was measured through debriefings and impact on ED workflow. Results: Seventy-six multidisciplinary medical and logistical staff and learners participated in this exercise. Using a framework analysis, the following LSTs were identified: 1) Significant communication difficulties within the shooting area, 2) Safe access and transport for internal casualties, 3) Difficulty accessing hospital resources (blood bank) 4) Challenges coordinating response with external agencies (police, EMS) and 5) Delay in setting up an off-site command centre. Conclusion: In situ simulation represents a novel approach to the development of Code Silver alert processes. Findings from ethnographic observations and a video-based analysis form a framework to address safety, logistical and medical response considerations.
P011: Discerning perceived barriers and facilitators to goals of care discussion in the emergency department: A survey of emergency physicians and residents
Authors: Argintaru N. , Vaillancourt S. , Chartier L.B. , Lee J.S. , O’Connor E. , Hannam P. , Ovens H.J. , McGowan M. , Steinberg L. , Quinn K.
Published: May 2017

Introduction: Patients presenting to the Emergency Department (ED) may require clarification of their goals of care (GOC) to ensure they receive treatments aligned with their values. However, these discussions can be difficult to conduct for multiple reasons, including lack of time in a busy ED, competing priorities and a limited relationship with the patient. Few studies have examined the perceived challenges faced by Emergency Physicians in conducting GOC discussions. This study sought to contextualize and discern the barriers and facilitators to having these conversations as reported by Emergency physicians. Methods: An interdisciplinary team of Emergency Medicine, Palliative Care and Internal Medicine providers developed an online survey comprised of multiple choice, Likert-scale and open-ended questions to explore four domains of GOC discussions: training; communication; environment; and personal beliefs. Invitations and scheduled reminders were sent to 275 ED physicians at six academic sites in a Canadian urban centre, including 49 EM residents. Results: 105 (46%) staff physicians and 23 (47%) residents responded with similar representation from all sites. Differences were reported in the frequency of GOC discussions: 59% of staff physicians conduct several per month whereas 65% of residents conduct less than one per month. Most agreed that GOC discussions are within their scope of practice (92%), they feel comfortable (96%), and are adequately trained (73%) to have them; however, 66% reported difficulty initiating GOC discussions. 73% believed that admitting services should conduct GOC discussions, yet acuity was noted in the comments as a major determinant with initiating GOC discussions by ED physicians. Main barriers identified were lack of time, chaotic environment, lack of advanced directives and the inability to reach substitute decision makers. 54% of respondents indicated that the availability of 24-hour Palliative Care consults would facilitate GOC discussions in the ED. Conclusion: Emergency physicians are prepared to conduct goals of care discussions, but often believe they should instead be conducted by the patient’s admitting service. Multiple perceived barriers to goals of care discussion in the ED were identified, and a majority of respondents felt that the availability of Palliative Care in the ED may facilitate these discussions.
P012: Québec emergency physicians propose priority solutions to improve rural emergency care
Authors: Audet J. , Lapointe L. , Renaud M. , Turgeon-Pelchat C. , Mathieu B. , Fleet R.
Published: May 2017

Introduction: In the province of Québec, roughly 20% of the population lives in rural areas. Rural emergency departments (EDs) face different challenges than their urban counterparts. Yet, few studies have sought to understand these challenges. This study aims to survey Québec’s emergency physicians to: 1) identify problems specific to rural EDs, 2) find solutions for improving accessibility and quality of care offered in rural regions and, 3) rank solutions in order of priority. These results will allow data triangulation with other of our studies that seek to identify challenges faced by rural EDs and potential solutions. Methods: During the 2016 annual conference of the Québec Emergency Physicians’ Association, we asked physicians and residents (including those from urban EDs), to complete a survey about the challenges faced by rural EDs. The survey contained two sections. The first took the form of open-ended questions in which respondents could write three challenges about accessibility and quality of care in rural EDs (objective 1) and three solutions to address these challenges (objective 2). The second section listed 11 potential solutions identified in our previous study. The solutions were ranked based on their priority level on a five-point Likert scale that ranged from “not a priority” to “an absolute priority” (objective 3). We added the total number of points for each solution and produced a ranking list. Results: Ninety-one physicians out of the 417 at the conference completed the survey; 58% came from urban EDs and 42% from rural EDs. Open-ended questions suggest that access to specialists and interfacility transfers are the principal challenges faced by rural EDs. The top five solutions identified as the highest priorities were: 1) care protocols, 2) improvement of interfacility transfers, 3) training with simulators, 4) targeted ultrasound and, 5) implementation of staff retention and recruitment strategies. Conclusion: This study is relevant and useful as roughly a quarter of attendants at the conference spontaneously volunteered to help identify and prioritize solutions to foster the accessibility and quality of care in rural EDs. Furthermore, it represents a stepping stone for our recently-launched wide-scope study, Urgences Rurales 360, that aims to explore problems faced by every of the 28 rural EDs in Québec and the solutions that could be implemented to resolve them.
P019: Prehospital diversion of intoxicated patients to a detoxification facility vs the emergency department: safety and compliance of an EMS direct transport protocol
Authors: Bismah V. , Prpic J. , Michaud S. , Sykes N.
Published: May 2017

Introduction: Prehospital transport of patients to an alternative destination (diversion) has been proposed as part of a solution to overcrowding in emergency departments (ED). We evaluated compliance and safety of an EMS bypass protocol allowing paramedics to transport intoxicated patients directly to an alternate facility [Withdrawal Management Services (WMS)], bypassing the ED. Patients were eligible for diversion if they were ≥18 years old, classified as CTAS level III-IV, scored <4 on the Prehospital Early Warning (PHEW) score, and did not have any vital sign parameters in a danger zone (as per PHEW score criteria). Methods: A retrospective analysis was conducted on intoxicated patients presenting to Sudbury EMS. Data was abstracted from EMS reports, hospital medical records, and discharge forms from WMS. Protocol compliance was measured using missed protocol opportunities (patients eligible for diversion but taken directly to the ED) and protocol noncompliance rates; protocol safety was measured using protocol failure (presentation to ED within 48 hours of appropriate diversion) and patient morbidity rates (hospital admission within 48 hours of diversion). Data was analysed qualitatively and quantitatively using proportions. Results: EMS responded to 681 calls for intoxication. Of the 568 taken directly to the ED, 65 met diversion criteria; these were missed protocol opportunities (11%). 113 patients were diverted. There was protocol noncompliance in 41 cases (36%), but 35 were due to incomplete recording of vital signs. There were direct protocol violations in only 6 cases (5%). There was protocol failure in 16 cases (22%), and patient morbidity in 1 case (1%). No patients died within 48 hours of diversion. Conclusion: EMS providers were fairly compliant with the protocol when transporting patients directly to the ED. There was some protocol non-compliance with patients diverted to WMS, though this is largely attributed to incomplete recording of vital signs; direct protocol violations were low. The protocol provides high levels of safety for patients diverted to WMS. Broader implementation of the protocol could reduce the volume of intoxicated patients seen in the ED, and improve quality of care received by this population.
P022: Physician reporting of medically unfit drivers: barriers and incentives
Authors: Brubacher J.R. , Renschler C. , Gomez A.M. , Huang B. , Lee W.C. , Erdelyi S. , Chan H. , Purssell R.
Published: May 2017

Introduction: Most medically unfit drivers are not reported to licensing authorities. In BC, physicians are only obligated to report unfit drivers who continue to drive after being warned to stop. This study investigates barriers to and incentives for physician reporting of medically unfit drivers. Methods: We used an online survey to study physician-reported barriers to reporting medically unfit drivers and their idea of incentives that would improve reporting. Email invitations to participate in the survey were sent to all physicians in BC through DoctorsofBC and to all emergency physicians (EPs) in the UBC Department of Emergency Medicine. Results: We received responses from 242 physicians (47% EPs, 40% GPs, 13% others). The most common barrier to reporting was not knowing which unfit drivers continue to drive (79% of respondents). Other barriers included lack of time (51%), lack of knowledge of the process, guidelines, or legal requirement for reporting (51%, 50%, 45% respectively), fearing loss of rapport with patients (48%), pressure from patients not to report (34%), lack of remuneration (27%), and pressure from family members not to report (25%).EPs were significantly less likely than other physicians to cite loss of rapport, pressure from patients, or pressure from family as barriers, but more likely to cite not being aware of drivers who continue to drive after being warned, lack of knowledge (regarding legal requirements to report, guidelines for determining fitness, and the reporting process), and lack of time. Factors that would increase reporting unfit drivers included better understanding of criteria for fitness to drive (70%), more information regarding how to report (67%), more information on when to report (65%), and compensation (43%).Free text comments from respondents identified other barriers/incentives. Reporting might be simplified by telephone hotlines or allowing physician designates to report. Physicians feared legal liability and suggested the need for better medico-legal protection. Loss of patient rapport might be minimized by public education. Failure of response from licensing authorities to a report (long wait times, lack of feedback to physician) was seen as a barrier to reporting. Conclusion: We identified barriers to physician reporting of medically unfit drivers and incentives that might increase reporting. This information could inform programs aiming to improve reporting of unfit drivers.
P024: Physician reporting of medically unfit drivers: knowledge, attitudes, and practice
Authors: Brubacher J.R. , Renschler C. , Huang B. , Lee W.C. , Gomez A.M. , Chan H. , Erdelyi S. , Purssell R.
Published: May 2017

Introduction: Medical conditions that impair perception, cognition or motor skills may make people unfit to drive. Reporting unfit drivers to licensing authorities is seen by many as a public health obligation. This study investigates physician knowledge, attitudes and practice around the management of medically unfit drivers. Methods: We used an online survey to explore physician knowledge of fitness to drive issues and their attitudes and practice with regard to counselling and reporting unfit drivers. Email invitations to participate in the survey were sent to all physicians in BC through DoctorsofBC and to all emergency physicians (EPs) in the UBC Department of Emergency Medicine. Results: We received responses from 242 physicians (47% EPs, 40% GPs, 13% others). The majority (78%) reported little/no knowledge on determining driver fitness and 94% had little/no training around guidelines, reporting, and laws involving fitness to drive. Most (88%) agreed that physicians should be obligated to advise medically unfit patients not to drive, and 74% reported that they often warn patients not to drive. The majority of physicians also chart their opinion of patients’ fitness to drive (67% do so more than twice per year). Most respondents (70%) indicated that it is “always appropriate” to report definitely unfit drivers whereas only 25% indicated that it is “always appropriate” to report potentially unfit drivers. However, in practice physicians see far more unfit drivers than they report to licensing authority: 67% of physicians encounter definitely unfit drivers more than twice per year but only 19% report definitely unfit drivers more than twice per year and 34% never report definitely unfit drivers. Compared to other physicians, EPs reported less knowledge and training about criteria for determining fitness to drive, were more likely to feel that reporting unfit drivers was not their responsibility, and were less likely to report unfit drivers to licensing authorities. Conclusion: Our findings indicate a need for more education and information resources to help physicians, particularly EPs, identify and manage medically unfit drivers. Although most physicians warn unfit drivers not to drive and document this in medical records, many medically unfit drivers are not reported to licensing authorities, a potential public health problem that should be further investigated.
P025: The Dunning-Kruger effect in medical education: double trouble for the learner in difficulty
Authors: Bryan J. , Lindsay H.
Published: May 2017

Introduction: It is difficult for learners to perform accurate self-assessments. This difficulty may be exaggerated in unskilled learners, a phenomenon termed the Dunning-Kruger Effect (Dunning & Kruger, 1999). Learners with the least amount of knowledge or skill may paradoxically be more likely to evaluate themselves favorably compared with their peers. This phenomenon is particularly relevant in medicine where we rely on self-directed learning not only in many of our undergraduate and postgraduate programs, but in guiding the pursuit of continuing medical education. The objectives of this study are to 1) determine whether the Dunning-Kruger Effect is present in medical education settings, 2) to determine the quality of studies in this area, and 3) to determine how this effect, if present, could influence approaches to the learner in difficulty. Methods: This is a review of the literature. PubMed databases were searched for all relevant articles. Included studies reported self-assessment of medical trainees or staff and comparison with an external rating. Studies were identified using select keywords and MeSH terms. Only studies published in English were included. No publication date limits were adopted. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality. Both authors independently abstracted data and rated study quality. Results: Eighty-six articles were identified in the PubMed search. On abstract review, 45 studies were found to meet criteria for further full article review. Studies were variable in setting and approach to self and external assessment. Criteria were not met for pooled analyses/meta-analysis. Results are presented as a summary of findings with special consideration of findings based on level of training (undergraduate, postgraduate, staff clinician). Conclusion: This review summarizes the current literature on the Dunning-Kruger Effect in medical education and provides an assessment of the quality of studies in this area to date. The potential relevance of the Dunning-Kruger Effect in medical education is discussed as are implications for interventions to support the learner in difficulty. Additional study in this area is indicated, in particular given the significant upcoming changes to postgraduate medical education in Canada in the era of Competence By Design (CBD).
P032: Identifying the bleeding and thrombosis learning needs of the Free Open Access Medical education (FOAM) community
Authors: Chan T.M. , Jo D. , Candidate MD , Shih A. , Bhagirath V. , Yeh C. , Castellucci L. , Thoma B. , de Wit K.
Published: May 2017

Introduction: Developing structured online educational curricula that meet learner needs is challenging. Thrombosis and bleeding are areas of innovation and change in emergency medicine. We aimed to determine the learning needs of the Free Open Access Medical education (FOAM) community with the subsequent goal of developing structured curricula to meet them. Methods: A Massive Online Needs Assessment (MONA) was conducted to determine the perceived and unperceived educational needs in thrombosis and bleeding. The survey was designed by a multidisciplinary team of experts and was open from September 20 to December 10, 2016. The survey requested limited demographic information and contained questions to identify topics of interest. Respondents’ baseline knowledge and unperceived needs were assessed using 5 case scenarios containing 3 questions each. Knowledge gaps were defined a priori as topics where <50% of participants answered correctly. Results: We received 198 complete responses by staff physicians (n=109), residents (n=46), medical students (n=29) and allied health professionals (n=14) from 20 countries. 116/198 responses were from people working in emergency medicine. Topics of interest to participants included choice of anticoagulants, interruption of anticoagulation, management of bleeding and monitoring anticoagulation. Knowledge gaps were identified in 4 main areas including interruption of anticoagulation, management of bleeding (including reversal of anticoagulation and massive transfusion), inherited thrombophilia, and screening for malignancy in acute thrombosis. Conclusion: We have identified six priority topics to cover in our future online Thrombosis and Bleeding curriculum by surveying the online medical community. Although perceived and unperceived needs showed high congruence, two priority topics were only identified by assessing unperceived needs.
P033: To choose or not to choose: evaluating the impact of a Choosing Wisely knowledge translation initiative on urban and rural emergency physician guideline awareness
Authors: Chandra K. , Atkinson P.R. , Fraser J. , Chatur H. , Adams C.
Published: May 2017

Introduction: Choosing Wisely is an innovative approach to address physician and patient attitudes towards low value medical tests; however, a knowledge translation (KT) gap exists. We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC) EM recommendations. We then assessed whether a structured KT initiative affected knowledge and awareness. Methods: Physicians working in urban (tertiary teaching hospital, Saint John, NB) and rural (community teaching hospital, Waterville, NB) emergency departments were asked to participate in a survey assessing awareness and knowledge of the first five CWC EM recommendations before an educational intervention. The intervention consisted of a 1-hour seminar reviewing the recommendations, access to a video cast and departmental posters. Knowledge was assessed by asking respondents to identify 80% or more of the recommendations correctly. Physicians were surveyed again at a 6-month follow up period. The Fisher exact test was used for statistical analyses. A sample size of 36 was required to detect a 30% change with an alpha of 0.05 and a power of 80%. Results: At the urban site, 16 of 25 (64%) physicians responded to the pre- and 14 of 26 (53.8%) responded to the post-intervention survey. Awareness of the EM recommendations did not increase significantly (81.3% pre; 95% CI 56.2-94.2 vs. 92.9% post; 66.4-99.9; p=0.60). There was a weak trend towards improved knowledge with 62.5% (38.5-81.6) of physicians responding correctly initially, and 85.7% (58.8-97.2; p=0.23) after the intervention. At the rural site, 8 of 11 (72.7%) physicians responded to the pre- and post-intervention survey. There was a trend towards improved awareness, (25% pre; 6.3-59.9 vs. 75% post; 40.1-93.7; p=0.13), with 50% (21.5-78.5) responding correctly pre, and 87.5% (50.8-99.9; p=0.28) after the intervention. Conclusion: We have described the current awareness and knowledge of the CWC EM recommendations. Limited by our small sample size, we report a trend towards increased awareness and knowledge at 6 months following our KT initiative in a rural setting where there was a low baseline awareness. At the urban site where baseline knowledge was high, changes seen were less significant. Further work will look at the effectiveness of our initiative on physician practice.
P034: Pediatric emergency department return visits: a proactive approach to quality improvement
Authors: Ostrow O. , Shim A. , Azmat S. , Chartier L.B.
Published: May 2017

Introduction: Emergency Department (ED) return visits leading to admission (RVs) are a well-recognized quality metric that can potentially signal gaps in patient care. Routine capture, investigation and monitoring of monthly ED RVs provides a better understanding of patient and visit- level factors associated with a return, which can then inform system-level quality improvement (QI) opportunities. The objective of this study is to develop a sustainable database that routinely tracks and analyzes pediatric ED RVs in a large Canadian children’s hospital to understand recurring themes and inform QI initiatives. Methods: Using a computerized record system, all 72-hour RVs are collected and reviewed for patient and visit-level variables. Clinicians receive monthly notification of their RVs and assist with completing root cause analyses. Ongoing cumulative analyses using descriptive statistics and t-test analysis are reviewed to identity trends and predictors of RVs. Targeted solutions are sought to address system-level themes through educational, quality, safety and administrative avenues. Results: The RV database contains almost three years of data analyzing approximately 1,500 cases, equaling 0.75% of our annual ED patient volumes. RVs have higher acuity scores on both their index and return visit (P=0.001) and children under 12 months of age have significantly higher rates of return (24% vs 16%, P<0.001). A consultation service was involved during 31% of the index ED visits, with the top three consultants being Hematology/Oncology (23%), General Surgery (12%), and Neurology (8%). The root cause of the majority of RVs were related to disease progression (65%), while 8% were call-backs for positive blood cultures or discrepant results, and 6% were categorized as a misdiagnoses. Completed quality improvement initiatives to date include the ED Sickle Cell Optimization Program, the Culture Follow-up and Escalation Algorithm, and the Young Infant Fever Pathway and Order Set. Conclusion: Routine monitoring and investigation of ED RVs provides a proactive approach to seeking improvement opportunities. With a better understanding of specific patient and visit-level factors associated with RVs, future system-level quality improvement initiatives can be targeted.
P035: Development of a province-wide audit program for return visits to the emergency department
Authors: Chartier L.B. , Ostrow O. , Yuen I. , Kutty S. , Davis B. , Hayes E. , Fairclough L. , Ovens H.J.
Published: May 2017

Introduction: Routine auditing of charts of patients with an emergency department (ED) return visit (RV) resulting in hospital admission can uncover quality and safety gaps in care. This feedback can be helpful to clinicians, administrators, and leaders working to improve clinical outcomes, increase patient satisfaction, and promote high-value care. Health Quality Ontario (HQO) has been tasked by Ontario’s Ministry of Health and Long-Term Care (MOHLTC) to manage the newly created ED RV Quality Program (RVQP), which mandates EDs participating in the Pay-for-Results (P4R) program to audit a minimum of 25-50 RVs/year. The goal of the first-ever ED-specific province-wide Quality Improvement (QI) initiative of this kind is to promote a culture of QI that will lead to improved patient care. Methods: Participating hospitals receive quarterly confidential reports from Access to Care (ATC) that show their and other hospitals’ rates of RVs, as well as identifying information for patients meeting RV inclusion criteria at their ED (within 72 hrs of index visit, or within 7 days with specific diagnoses). HQO has partnered with QI experts and ED physician-leaders to develop various guidance materials. These materials have been disseminated through various media. Hospitals are conducting audits to identify underlying quality issues, take steps to address the underlying causes, and submit reports to HQO. A taskforce will then analyze clinical observations, summarize key findings and lessons learned, and share improvements at a provincial level through an annual report. Results: Since its launch in April 2016, 73 P4R and 16 voluntarily enrolled non-P4R hospitals (which collectively receive approximately 90% of ED visits in the province) are participating in the RVQP. ED leaders have engaged their hospital’s leadership to leverage interest and resources to improve patient care in the ED. To date, hospitals have conducted thousands of audits and have identified quality and safety gaps to address, which will be analyzed in February 2017 for reporting shortly thereafter. These will inform QI endeavours locally and provincially, and be the largest source of such data ever created in Ontario. Conclusion: The ED RVQP aims to create a culture of continuous QI in the Ontario health care system, which provides care to over 13.8 million people. Other jurisdictions can replicate this model to promote high-quality care.