bluuebunny/crossref_metadata_2025 huggingface dataset:
P059: Paramedic compliance with a novel defibrillation strategy in a large, urban EMS system in the United States
Authors: Goodloe J.M. , Vinson L.D. , Cox M.L. , Burns B.D.
Published: May 2017

Introduction: Emergency Medical Services (EMS) care confers distinct impact upon survivability from sudden cardiac arrest. Many studies have been conducted regarding EMS interventions for cardiac arrest, though fewer studies have been published detailing specific analysis of paramedic compliance with standing orders, particularly those involving a novel energy strategy in defibrillation. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Education on a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was delivered in classroom and internet-accessed settings. Paramedics then performed hands-on practice in DSED. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT™, Physio-Control Corporation, Redmond, WA). All ECGs and defibrillation events were reviewed by an emergency physician to determine energy settings used by paramedics for determining the accuracy of compliance with protocol-based standing orders. Results: During the 5 month study period, the paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 76/90 (84.4%) with estimated weight <100 kg were treated with correct joule settings, though only 7/43 (16.3%) with estimated weight ≥100kg received all defibrillations at 360J as protocol-specified. 26/44 (59.1%) in refractory ventricular fibrillation, defined as requiring a fourth defibrillation, received DSED as protocol-specified. Conclusion: Paramedics, when specifically trained on a novel defibrillation strategy, involving both weight-based joule settings and use of DSED for refractory ventricular fibrillation, are inconsistently able to quickly and successfully incorporate that strategy in EMS resuscitation care. Further educational endeavours are warranted to achieve higher defibrillation strategy protocol compliance.
P063: Perceptions and reflections of Ethiopian emergency medicine graduates regarding the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) Curriculum: a qualitative evaluation study
Authors: Hunchak C. , Fremes E. , Kebede S. , Meshkat N.
Published: May 2017

Introduction: The first-ever EM postgraduate training program in Ethiopia was launched at Addis Ababa University in 2010. EM faculty from the University of Toronto were invited to design and implement an EM rotation-based curriculum with tri-annual teaching trips to support the overall AAU EM program. To date, three cohorts of EM specialists (n=15) have graduated from the three-year program. After six years of implementation, we undertook a qualitative evaluation of the TAAAC-EM curriculum. Methods: Data collection took place in 2016 in Ethiopia via in-person graduate interviews (n=12). Participants were interviewed by a trained research assistant who used a semi-structured interview guide. Standard interview, transcription and analysis protocols were utilized. Qualitative software (QSR-NVIVO 9) was used for thematic grouping and analysis. Results: Graduates of AAU’s EM residency training program reported very positive experiences with the TAAAC-EM curriculum overall. All graduates acknowledged the positive impact of TAAAC-EM’s emphasis on bedside teaching, a unique component of the TAAAC-EM model compared to traditional teaching methods at AAU. Graduates felt that TAAAC-EM teachers were effective in creating a novel culture of EM at AAU and in role-modeling ethical, evidence-based EM practice. When asked about specific areas for program improvement, the following themes emerged: 1) a desire to shift delivery of the didactic clinical epidemiology curriculum to the senior residency years (PGY2-3) to coincide with completion of a required residency research project; 2) a desire for increased simulation and procedural teaching sessions and 3) the need for more nuanced context specificity in the curriculum delivery to incorporate local guidelines and practice patterns. A lack of educational supports during non-TAAAC-EM visits was also identified as an area for further work. Conclusion: Interviewing graduates of AAU’s EM residency training program proved important for determining areas of curriculum improvement for future trainees. It also provided critical input to TAAAC-EM strategic planning discussions as the partnership considers expanding its scope beyond Addis Ababa.
P064: Coastal family practice residency: simulation curriculum needs assessment survey
Authors: Innes K.C. , Chestnut S. , Schafer K. , Khazei A.
Published: May 2017

Introduction/Innovation Concept: Medical simulation is becoming increasingly useful for healthcare education. Simulation-based crisis resource management (CRM) has been shown to produce improvements in skill acquisition, communication and team behaviors. Simulation has become a key component of most Family Practice (FP) residency programs and many programs are moving towards developing formal simulation curriculums. The Coastal FP Residency is a relatively new and unique program with a large emphasis on rural medicine. Graduates have gone on to practice in remote areas with less access to supports for critically ill patients. Therefore, an effective simulation curriculum, focused on Emergency Medicine, is of great importance to this program. Methods: To develop our curriculum, Kern’s framework for medical education was selected given its prior success in similar endeavors. The first step of this approach involves a needs assessment, which we accomplished in the form of an online survey. The questionnaire included pre-defined topics pertaining to the training needs of FP Residents destined for Rural Practice with respect to technical skills, CRM skills, specific medical conditions and categories of medical conditions. Classification of answers included multiple choice, 5-point Likert scales as well as an option for free-text answers. The survey was distributed to pre-identified participants including stakeholders/educators within the Coastal FP residency program as well as simulation education leads for FP residencies throughout British Columbia (BC). Current residents, as well as program graduates were also asked to complete the survey. Curriculum, Tool, or Material: The results of this survey were used to develop formal goals and objectives which were in turn used to write or adapt 24 cases for the curriculum. Cases from categories (e.g. Pediatrics) rated as “Extremely Important” on the Likert scale were included proportionally more in the curriculum. The cases were also designed to assess/practice a higher proportion of CRM elements considered important and to address commonly identified difficulties in resuscitation. Cases were developed, where possible, using local or national guidelines and are currently in the stage of peer review (by a minimum of two peers). Conclusion: The curriculum will be implemented in July 2017 and we will transition towards the evaluation phase. Our goal is to develop and distribute formalized needs assessments to rural FP residencies across BC so that they may develop dynamic, formal curriculums of their own.
P068: Patient satisfaction following educational ultrasounds in the emergency department
Authors: Kapur P. , Betz M. , Chenkin J. , Brick C.
Published: May 2017

Introduction: Development of point-of-care ultrasound (POCUS) image-generating skills requires residents to practice on patients awaiting care in the emergency department (ED) for unrelated reasons. While patients are almost universally agreeable to the scans, there is the possibility that they feel pressured to do so and may have negative experiences that go unreported. The objective of this study was to determine the self-reported patient satisfaction and identify any concerns after educational ultrasounds performed in the ED. Methods: We conducted a survey of patients at a single academic ED. Patients were eligible for enrollment if they had volunteered for an ultrasound when study personnel were available. The survey was administered by a representative from the Patient Affairs Department who advised the patients that the results would remain anonymous and would have no impact on their care. The survey included patient demographics, questions about the consent process, communication by the trainee, adverse reactions and patient satisfaction. The primary outcome was the overall satisfaction level reported by the volunteer patients on a 5-point Likert scale. Secondary outcomes included identification of any discomfort or concerns about the process as expressed by patients. Simple descriptive statistics were used to report survey results. Results: Ninety-nine patients fully completed the questionnaire. Fifty (50%) were women. The age range was 18 to 99 years. Satisfaction among volunteers was high, with 94% of respondents giving a rating of 4 or 5 (five being an excellent experience). No patients gave a negative rating (1 or 2). Three (3%) patients felt “somewhat” pressured to volunteer. A majority of patients (72%) experienced no discomfort during the scan however 16% experienced some physical discomfort. Comments indicated that too much pressure applied with the ultrasound probe or cold ultrasound gel were the main sources of discomfort. Despite some discomfort 95 (95%) patients stated they would likely volunteer again if asked in the future. Conclusion: ED patients volunteering as models for residents learning POCUS expressed generally positive perceptions of their experience. While only a small minority of patients experienced some discomfort or felt pressured into participating, it is important to ensure that patients have a process to communicate any concerns about educational ultrasounds in the ED.
P071: Choosing Wisely in the emergency department: exploring the reach, support and potential for the Choosing Wisely Canada® campaign among emergency physicians
Authors: Krebs L. , Chartier L.B. , Holroyd B.R. , Dowling S. , Cheng A.H. , Villa-Roel C. , Campbell S.G. , Couperthwaite S. , Rowe B.H.
Published: May 2017

Introduction: Choosing Wisely Canada® (CWC) launched in April 2012. Since then, the Emergency Medicine (EM) top-10 list of tests, treatments and procedures to avoid has been released and initiatives are on-going. This study explored CWC awareness and support among emergency physicians. Methods: A 60-question online survey was distributed to Canadian Association of Emergency Physicians (CAEP) members with valid e-mails. The survey collected information on demographics, awareness/support for CWC as well as physicians’ perceived barriers and facilitators to implementation. Descriptive statistics were performed in SPSS (Version 24). Results: Overall, 324 surveys were completed (response rate: 18%). Respondents were more often male (64%) and practiced at academic/tertiary care hospitals (56%) with mixed patient populations (74%) with annual ED volumes of >50,000 (70%). Respondents were familiar with campaigns to improve care (90%). Among these respondents, 98% were specifically familiar with CWC and 73% felt these campaigns assisted them in providing high-quality care. Respondents felt that the top-5 EM recommendations were supported by high quality evidence, specifically the first 4 recommendations (>90% each). The most frequently reported barriers to implementation were: patients’ expectations/requests (33%), the possibility of missing severe condition(s) (20%), and requirements of ED consultations (12%). Potential facilitators were identified as: strong evidence-base for recommendations (37%), medico-legal protection for clinicians who adhere to guidelines (13%), and support from institutional leadership (11%). Conclusion: CWC is well-known and supported by emergency physicians. Despite the low response rate, exploring the barriers and facilitators identified here could enhance CWC’s uptake in Canadian emergency departments.
P074: Clinician gestalt in the evaluation of pulmonary embolism risk factors: the CEPERF study
Authors: Lacombe S.P. , McLeod S.L. , Borgundvaag B.
Published: May 2017

Introduction: Pulmonary Embolism (PE) is a difficult to diagnose presentation associated with significant morbidity and mortality. Despite development of risk stratification tools (RST), physician gestalt continues to play a large role in the diagnostic evaluation of PE. Implicit in this gestalt is the evaluation of PE risk factors (RF). It is unknown, however, if physicians are similar and accurate in their assessment of known PE RF. Methods: An online survey presented paired comparisons (n=55) of 11 known PE RF to active Emergency Physicians (n=20), Family Doctors (n=11), and Residents (Family Medicine [n=20]; Emergency Medicine [n=5]). The Bradley-Terry Model converted the paired comparisons to rank order lists for the cohorts and these lists were compared. The perceived efficacy and use of RST and gestalt was also assessed across the cohorts. Results: The response rate was 72%. Emergency Physicians had the highest perception of gestalt as an effective method of risk stratification (7.4±1.4 out of 10) while Family Medicine Residents had the lowest (5.1±1.9). More than 95% of Emergency Physicians and Residents employed RST (PERC and Wells) compared to 46% of Family Physician respondents. Those who used RST utilized the tools in the majority of their clinical encounters (>75% of the time). There was good agreement between the cohorts in regards to their rank order lists (Tau-b ≥ 0.71). Age was identified as a RF which was consistently ranked lower than literature reported values amongst the cohorts. Conclusion: Physicians in various practice settings and levels of training rank PE risk factors similarly when forced to compare them. There are important RF, most notably age, which were identified in the current study that were consistently undervalued. This finding may highlight how RST are shaping perceptions of PE RF through their use and how age as a PE RF may warrant more attention in education and clinical assessments.
P077: Observance des médecins face aux indications de tomodensitométrie cérébrale chez les patients ayant subi un TCC léger et facteurs associés à la non-observance
Authors: Le Sage N. , Harton V. , Tardif P. , Neveu X. , Archambault P.M. , Émond M. , Chauny J. , Mercier E. , De Guise É. , Bergeron-Larose V.
Published: May 2017

Introduction: Lors d’un traumatisme cranio-cérébral léger, les complications hémorragiques sont rares et ne nécessitent qu’exceptionnellement une intervention neurochirurgicale (<1%). Dans le but de limiter les radiations inutiles et les coûts, Choosing Wisely s’est récemment positionnée avec CAEP afin de recommander l’usage de la Canadian CT Head Rule (CCHR) suite un à TCCL. L’objectif principal de cette étude vise à évaluer l’observance des médecins d’urgence concernant l’utilisation de la règle CCHR chez les patients ayant subi un TCCL. L’objectif secondaire consiste à identifier les facteurs associés au risque de non-observance dans cette situation clinique. Methods: Des analyses univariées et multivariées ont été effectuées sur les données de 854 patients ayant subi un TCCL et ayant été recrutés dans les 24 heures suivant leur visite dans un centre tertiaire québécois de traumatologie. Des analyses descriptives ont permis d’estimer la proportion de médecins d’urgence ayant utilisé les critères de la règle CCHR et ceux n’ayant pas été observants. Nous avons ensuite évalué les facteurs potentiellement associés au risque de non-observance. Results: 62.9% des patients avec TCCL ont subi une TDM au département d’urgence. La non observance globale des médecins face à la règle était de 29.9%. De plus, la proportion de TDM effectuée sans indication selon la règle est égale à 20% (177/854). Les facteurs suivants semblent associés au risque de surutilisation de la TDM: la prise d’acide acétylsalicylique (RR=1.8, [IC 1.3-2.6]), la présence de céphalée décrite par le patient au moment de l’évaluation (RR=1.5, [IC 1.2-1.9]), et l'âge (55-64 ans versus moins de 55 ans) (RR=1.6 [IC 1.2-1.9]). Conclusion: L’évaluation de l’observance des médecins face à ces recommandations, combinée à l’identification des facteurs en cause lors de la non-observance favoriseront une meilleure orientation des interventions de transfert de connaissances dans le futur en plus d’améliorer la qualité des soins et l’efficience des ressources.
P079: Manual pressure (the modified peace sign) as an aid to sonographic aortic visualization-a pilot study
Authors: Leech-Porter K. , Lewis D. , Fraser J. , Atkinson P.R.
Published: May 2017

Introduction: Point-of-care-ultrasound is an established tool in the early diagnosis of abdominal aortic aneurysm (AAA), with a reported pooled sensitivity of 97.5% and pooled specificity 98.9%. Despite these impressive numbers, body habitus and bowel gas often render emergency department (ED) PoCUS for AAA inconclusive. We devised a manual aid “the modified peace sign technique” to improve visualization of the aorta, consisting of placing the divided fingers of the free hand of the sonographer around the probe to increase gas dispersion and improve the view of the obscured aorta. We tested the technique on volunteers during a training course when the initial scan was indeterminate due to inability to view the aorta from sub-xiphoid to bifurcation. Methods: In our pilot study, 7 physicians were asked to make a best attempt to perform an aortic scan. If they were unable to visualize the aorta, they were asked to use the modified peace sign technique. Participants recorded the number of times which they used the technique and the frequency that the technique allowed for a complete aortic scan, previously unobtainable. All scans were supervised by certified PoCUS physicians. Results: The technique was used a total of 25 times. Following failure to complete an aortic scan using their best attempt, participants were subsequently able to obtain a complete aortic scan 70% (95% CI 48 to 83%) of the time using the modified peace sign technique. Conclusion: In our pilot study, the modified peace sign technique had an estimated effect size of 70% improvement for visualization of the aorta in volunteers. Further studies are required to validate the technique in clinical practice.
P081: Combative patients given prehospital midazolam as a chemical restraint: adverse events and efficacy in the emergency department
Authors: Davis M. , Leggatt L. , Van Aarsen K. , Bradford P. , Morassutti P. , Leschyna M.W.
Published: May 2017

Introduction: Paramedics are required to manage combative patients. In order to do so safely, chemical sedation may be required. Advanced Care Paramedics in our EMS system utilize midazolam for chemical restraint. Our previous research has shown that midazolam appears to have few prehospital adverse events (AEs) associated with its use. However, it required multiple dosages in 33.3% of patients and was deemed ineffective in 15.1% of patients that received it in the prehospital setting. Objective: To determine Emergency Department (ED) AEs associated with the prehospital use of midazolam in combative patients and determine the efficacy of this agent as a chemical restraint during the first hour of the ED stay. Methods: A retrospective chart review of paramedic calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were examined. Patients were excluded if they were 17 or younger. Ambulance call records were linked to the patient’s ED chart. ED charts were reviewed and a priori endpoints were extracted. Results: Of approximately 350,000 calls, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam in the prehospital setting. During the first hour of their ED stay, 68 (36.5%) required further sedation, while 118 (63.4%) patients did not. Of the 186 patients who received midazolam in the prehospital setting there was one death and one AE in the ED (defined as hypotension, bradypnea, or need for airway intervention). After further review of the charts, both AEs were deemed likely resulting from underlying pathology and not related to the use of midazolam. The average ED Length of stay (LOS) was 7.6 hours for all patients. A total of 82 (44.1%) were admitted to hospital with a mean in hospital LOS of 13.1 days. Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with no reported delayed AEs. 36.5% of this cohort required further sedation within 1 hour of their ED arrival. This supports previous findings that midazolam was ineffective in 15.1 % of prehospital combative patients. Further study is required to determine midazolam’s efficacy and AE profile compared to other prehospital agents in order to ensure optimal safety of both patients and paramedics.
P086: Effectiveness of interventions to decrease imaging among emergency department low back pain presentations: a systematic review
Authors: Lui C. , Desai S. , Krebs L. , Kirkland S.W. , Keto-Lambert D. , Rowe B.H.
Published: May 2017

Introduction: Low back pain (LBP) is an extremely frequent emergency department (ED) presentation. Although LBP imaging often results in no change to the ED management, does not identify abnormalities, and has documented risks (e.g., radiation exposure), advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging [MRI]) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness and safety of interventions aimed at reducing imaging in the ED for LBP patients. Methods: Six bibliographic databases and grey literature were searched. Comparative studies assessing interventions aimed at reducing ED imaging for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility, completed data extraction, and assessed the quality of included studies. Due to a limited number of studies and significant heterogeneity, a descriptive analysis was performed. Results: The search yielded 510 unique citations of which three before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and post-intervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The interventions to reduce lumbar spine imaging varied considerably. Study interventions included: 1) clinical decision support (i.e., a specialized X-ray requisition form), which reported a 47.4% relative reduction of lumbar spine radiography referrals; 2) clinical decision guidelines, which reduced referrals by 43.8%; and 3) multidisciplinary protocols, which reported a reduction in the MRI referral rate by 26.1%. Despite reductions in simple imaging, CT use increased in two of the three studies. Conclusion: LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation). Yet, evidence of interventions’ effectiveness in reducing imaging for ED patients with LBP is sparse. While there is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED, unintended consequences have been reported and additional studies employing higher quality methods are strongly recommended.
P089: Does the use of ultrasound improve diagnosis during simulated trauma scenarios?
Authors: McLean D. , Hewitson L. , Lewis D. , Fraser J. , Mekwan J. , French J. , Verheul G. , Atkinson P.R.
Published: May 2017

Introduction: Point of care ultrasound (US) is a key adjunct in the management of trauma patients, in the form of the extended focused assessment with sonography in trauma (E-FAST) scan. This study assessed the impact of adding an edus2 ultrasound simulator on the diagnostic capabilities of resident and attending physicians participating in simulated trauma scenarios. Methods: 12 residents and 20 attending physicians participated in 114 trauma simulations utilizing a Laerdal 3G mannequin. Participants generated a ranked differential diagnosis list after a standard assessment, and again after completing a simulated US scan for each scenario. We compared reports to determine if US improved diagnostic performance over a physical exam alone. Standard statistical tests (χ2 and Student t tests) were performed. The research team was independent of the edus2 designers. Results: Primary diagnosis improved significantly from 53 (46%) to 97 (85%) correct diagnoses with the addition of simulated US (χ2=37.7, 1df; p=<0.0001). Of the 61 scenarios where an incorrect top ranked diagnosis was given, 51 (84%) improved following US. Participants were assigned a score from 1 to 5 based on where the correct diagnosis was ranked, with a 5 indicating a correct primary diagnosis. Median scores significantly increased from 3.8 (IQR 3, 4.9) to 5 (IQR 4.7, 5; W=219, p<0.0001).Participants were significantly more confident in their diagnoses after using the US simulator, as shown by the increase in their mean confidence in the correct diagnosis from 53.1% (SD 22.8) to 83.5% (SD 19.1; t=9.0; p<0.0001)Additionally, participants significantly narrowed their differential diagnosis lists from an initial medium count of 3.5 (IQR 2.9, 4.4) possible diagnoses to 2.4 (IQR 1.9, 3; W=-378, p<0.0001) following US. The performance of residents was compared to that of attending physicians for each of the above analyses. No differences in performance were detected. Conclusion: This study showed that the addition of ultrasound to simulated trauma scenarios improved the diagnostic capabilities of resident and attending physicians. Specifically, participants improved in diagnostic accuracy, diagnostic confidence, and diagnostic precision. Additionally, we have shown that the edus2 simulator can be integrated into high fidelity simulation in a way that improves diagnostic performance.
P094: Meeting patient expectations in the emergency department: preliminary findings from the preparing emergency patients and providers study
Authors: Nunn J. , Cassidy C. , Chiasson D. , MacPhee S. , Curran J.
Published: May 2017

Introduction: Effective communication to develop a shared understanding of patient expectations is critical in establishing a positive medical encounter in the emergency department (ED). However, there is limited research examining patient/caregiver expectations in the ED, and their impact on the beliefs, attitudes and behaviours during and after an ED visit. The objective of this study is to examine patient/caregiver expectations and satisfaction with care in the ED using a patient expectation questionnaire and a follow up survey. Methods: As a part of a larger 3-phase study on patient/caregiver expectations in adult and pediatric EDs, a 7-item, paper-based questionnaire was distributed to all patients and/or caregivers who presented to one of four EDs in Nova Scotia with a Canadian Triage and Acuity Scale (CTAS) score of 2 to 5. A follow-up survey was distributed to all willing participants via email to determine their satisfaction with care received in ED. Descriptive statistics were used to analyze responses. Results: Phase 1 was conducted from January to September 2016. In total, 24,788 expectation questionnaires were distributed to ED patients/caregivers, 11,571 were collected (47% response rate), and 509 patients were contacted for a follow-up survey. Preliminary analysis of 4,533 questionnaires shows the majority of patients (67.1%) made the decision by themselves to present to the ED, while others were advised by a family/friend (22%). Respondents were most worried about an injury (17.8%) followed by illness (15.6%) and expected to talk to a physician (69.9%) and receive an x-ray (39.3%). The majority of physicians (53.3%) reported the expectation tool helped in caring for the patient and 87.5% felt they met patient expectations. There were 147 patient/caregiver responses to a follow-up survey (29% response rate) and 87.1% of responders reported that ED clinicians met their expectations. Conclusion: Patient/caregivers have a variety of concerns, questions, and expectations when presenting to the ED. Obtaining expectations early in the patient encounter may provide opportunities for improved communication between clinicians and patients while enhancing satisfaction with care received. Further analysis is needed to determine the impact of the expectation questionnaire on productivity in the ED.
P095: Wellness, sleep and exercise in emergency medicine residents: an observational study
Authors: Poonja Z. , O’Brien P.S. , Cross E. , Desrochers C. , Jaggi P.K. , Dance E. , Krentz J. , Thoma B.
Published: May 2017

Introduction: Burnout is well documented in residents and emergency physicians. Wellness initiatives are becoming increasingly prevalent, but there is a lack of data supporting their efficacy. In some populations, a relationship between sleep, exercise and wellness has been documented, but this relationship has not been established in emergency medicine (EM) residents or physicians. We aim to determine whether exercise and sleep quality and quantity as measured by a Fitbit are associated with greater perceived wellness in EM residents. Methods: Fifteen EM residents from two training sites wore a Fitbit during a 4-week EM rotation. The Fitbit recorded data on sleep quantity (minutes sleeping)/quality (sleep disruptions) and exercise quantity (daily step count)/quality (daily active minutes performing activity of 3-6 and >6 metabolic equivalents). Participants completed an end-of-rotation Perceived Wellness Survey (PWS) which provided information on six domains of personal wellness (psychological, emotional, social, physical, spiritual and intellectual). Associations between PWS scores and the Fitbit markers were evaluated using a Mann-Whitney-U statistical analysis. Results: Preliminary results indicate that residents who scored ≥50th percentile for sleep quantity had significantly higher PWS scores than those who scored ≤50th percentile (median PWS 17.0 vs 13.0 respectively, p=0.04). There was no significant correlation between PWS scores, sleep interruptions, daily step count and average daily active minutes. Postgraduate Year PGY1 and PGY2-5 report median PWS scores of 13.9 and 17.2 respectively. Conclusion: To our knowledge, this is the first study to objectively measure the quality and quantity of sleep as well as exercise habits of EM residents using a Fitbit device. Our data indicates a significant relationship between better sleep quantity and higher wellness scores in this population. We aim to enroll 30 residents in order to obtain a more robust data set. A larger sample size will increase statistical power and allow us to more extensively evaluate the use of exercise and sleep monitoring devices in the efficacy assessment of wellness initiatives.
P098: Addiction medicine training in Canadian emergency medicine residency programs: a needs assessment survey
Authors: Olmstead A. , Hann J. , Gupta S. , Jaggi P.K. , Dong K. , Ha D.
Published: May 2017

Introduction: Emergency department visits related to substance use are becoming more serious and increasingly costly in Canada. Emergency physicians must be able to effectively screen, manage, refer, and advocate for these complex patients. This study sought to describe the current state of addiction medicine training in Canadian emergency medicine (EM) residency programs and to assess the need for a formal curriculum. Methods: All Royal College and College of Family Physicians EM Program Directors (PDs) were asked to participate in a ten-question needs assessment survey on addiction medicine training for residents. Questions were developed through consensus after reviewing the relevant literature and conducting a formal pilot survey with staff physicians experienced in survey methodology. Responses were collected securely using the Research Electronic Data Capture (REDCap) database. Results: 19 out of 31 (62%) eligible PDs completed the survey. The importance of addiction medicine training received a median score of 69.5 (IQR=74.0) on a scale of 1-100. Most programs devoted two hours or less per year of formalized teaching on individual topics (such as opioids, alcohol, harm reduction) over the past two academic years. The two most common teaching modalities used were didactic lectures (15/19, 78.9%) and case-based tutorials (12/19, 63.2%). Case-based tutorials were identified as the most effective teaching method (12/19, 63.2%). Topics highlighted as most important to include in a curriculum were: screening for substance use disorders and referral for further treatment (14/19, 73.7%), social determinants of health (14/19, 73.7%), alcohol, opioid, and stimulant intoxication and/or withdrawal (14/19, 73.7% each), and management of patients on opioid agonist therapy (14/19, 73.7%). The most commonly perceived barriers to implementing such a curriculum were insufficient curriculum time (10/19, 52.6%) and lack of qualified teaching staff (7/19, 36.8%). Conclusion: This needs assessment provides an understanding of the current state of addiction medicine training for EM residents in Canada. A case-based addiction medicine workshop is currently being developed to address identified curriculum gaps. Integrating this curriculum longitudinally into a time-constrained academic schedule is an important next step.
P103: A human factors-based framework analysis for patient safety: the trauma resuscitation using in situ simulation team training (TRUST) experience
Authors: Petrosoniak A. , Fan M. , Trbovich P. , White K. , Pinkney S. , McGowan M. , Gray A. , Campbell D. , Rizoli S. , Hicks C.
Published: May 2017

Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.
P111: The social determinants of health in adults presenting to the ED with a mental health complaint
Authors: Salehmohamed Q. , Barbic D. , MacEwan W.G. , Kim B. , Mernoush V. , Khamda B. , Khoshpouri P. , Osati F. , Leon A. , Chau S. , Barbic S.
Published: May 2017

Introduction: The social determinants of health (SDoH) can play a significant role in a person’s overall wellbeing. This is especially true for adults with mental illness and mental health disorders. In this study, we describe the SDoH of patients presenting to an academic, inner-city emergency department (ED) with an acute mental health complaint (AMHC). Methods: We prospectively identified and enrolled a convenience sample of patients presenting to an ED with an annual census of 85,000 visits. Participants provided informed written consent, and completed a questionnaire package containing questions related to demographics and SDoH. As well, participants were asked to complete four mental health, quality of life, and recovery validated patient-reported outcome measures. Results: A total 108 participants were enrolled in this study, of which 65% were male, aged 37.5 years (IQR 26.7-50.3), 56% Caucasian, and 22% Aboriginal. Depression was the primary diagnosis reported by 55% of participants, with 58.9% meeting the PhQ-9 cutoff for moderate-severe depression. The highest level of educational achievement for 44% of participants was high school or less, with 75% reporting being unemployed. Almost half (45%) reported engaging in less than two hours of structured activity each week. Thirty eight percent of participants reported living in their own apartment, with 25% reporting being homeless and 17% living in a single-room housing unit. The majority of participants (56%) sampled were not satisfied with their housing, and 67% were actively looking for new housing. Sixty percent of participants reported smoking cigarettes daily and 40% reported weekly cannabis use. A total of 11% of the sample reported that they did not have access to clean drinking water; 35% worried that their food would run out, and 47% reported cutting the size of meals due to a lack of money. Conclusion: This study lends evidence towards the circumstances in which patients presenting to the ED with an AMHC live and work. A considerable proportion of patients reported homelessness or being marginally housed, lack access to clean drinking water and sufficient food, and high rates of unemployment. Mitigating the effects of harmful social determinants is critical for optimal health of this population. Future work is needed to clarify the role of the ED in the surveillance, screening, and intervention of SDoH for this vulnerable patient group.
P114: Critical objectives for a pediatric emergency medicine fellowship point of care ultrasound curriculum
Authors: Shefrin A.E. , Warkentine F. , Constantine E. , Toney A. , Uya A. , Doniger S.J. , Sivitz A. , Horowitz R. , Kessler D.
Published: May 2017

Introduction: Emergency Medicine Physicians have been incorporating Point-of-Care Ultrasound (POCUS) into their practice for over twenty years. Only recently has its use become more widespread in the practice of Pediatric Emergency Medicine (PEM). Recent guidelines have described the scope of applications for PEM physicians. However, no consensus exists as to which applications should be prioritized and routinely taught to PEM fellowship trainees and therefore expected of PEM graduates as they enter practice. The PEM POCUS Network, a multinational group of Physicians with POCUS expertise formed in 2014, set out to reach expert consensus as to which applications should be incorporated into PEM fellowship training curricula. Methods: A multinational group of PEM POCUS experts was recruited from the PEM POCUS Network via a screening process that identified PEM physicians who have performed over 1000 pediatric POCUS scans and met any of one of the following criteria: having 3 years or more experience teaching POCUS to PEM fellows, being local academic POCUS leaders or had completed a dedicated PEM POCUS fellowship. These experts rated each of the 60 possible PEM POCUS applications using a modified Delphi consensus building technique for their importance in inclusion into a PEM Fellowship curriculum. Consensus was reached when >80% of respondents agreed to include or exclude each item. Results: In the first round, 66 out of 92 (72%) PEM POCUS Network members responded to the survey email, of whom 45 met expert criteria and completed the first round. During round 1, consensus was reached to include 18 of the 60 applications in a PEM fellowship curriculum and to exclude 2 applications from a PEM fellowship curriculum. Eighty-two percent (37 /45) of the experts completed Round 2 where 40 items were rated; consensus was reached to include 3 additional applications and exclude 5 applications. The decision was made not to carry on with future rounds after this stage, since no significant changes were observed between the two rounds, with regard to items that had not reached consensus. Conclusion: This project of the PEM POCUS Network reached consensus on 21 applications that should be included in a PEM Fellowship curriculum. This project will have significant impact on how PEM fellowships teach POCUS to their trainees.
P123: Measuring health-related outcomes: is social desirability bias an issue we should be exploring while conducting emergency department research?
Authors: Villa-Roel C. , Borgundvaag B. , Majumdar S.R. , Leigh R. , Bhutani M. , Lang E. , Senthilselvan A. , Rosychuk R.J. , Rowe B.H.
Published: May 2017

Introduction: Social desirability bias is a systematic error in self-report measures resulting from the desire of respondents to avoid embarrassment and project a favourable image of themselves to others. This bias may decrease the accuracy of self-reported health outcomes collected in health research compromise the validity of research findings. This study compared outcomes obtained by patient self-report vs. the same outcomes after undergoing verification and external adjudication, in trial involving patients with acute asthma. Methods: Cross-sectional analysis of outcome data obtained in a randomized controlled trial conducted in 6 Canadian emergency departments (ED). Adult patients were allocated to receive usual care (UC), opinion leader [OL] guidance to their primary care provider (PCP), or OL guidance+nurse case-management [OL+CM] for patients (NCT01079000). Asthma relapses and PCP follow-up visits were blindly assessed through patient self-report 30 and 90 days after their ED presentation for acute asthma. Each reported event was verified through the provincial electronic medical record, the ED Information Systems, and by calling the PCPs’ offices. Two study investigators, blinded to the study interventions, independently reviewed and adjudicated the verified outcomes. Disagreements were resolved by consensus prior to un-blinding. Results: Overall, 367 patients were enrolled; more were female (64%) and the median age was 28 years. Overall, patient follow-up was obtained in 85% of cases. The proportion of asthma relapses occurring within the first 90 days were lower when considering patient self-report than when considering the adjudicated outcomes (17%[39/227] vs. 19%[70/367]). The proportion of PCP follow-up visits occurring within the first 30 days were higher when considering patient self-report than when considering the adjudicated outcomes (47%[139/290] vs. 40%[146/367]). The pattern was similar, regardless of the arm of the study (UC vs. OL vs. OL+CM arms); outcome disagreement did not influence the direction of magnitude of the treatment effect. Conclusion: Social desirability bias could have influenced the outcomes obtained by patient self-report in this ED-based study. The direction of the bias was the same for both outcomes; however, the variation did not change the study results. This bias may play a role in studies with smaller sample sizes.
P124: Determining ED staff awareness and knowledge of intimate partner violence and available tools
Authors: Vonkeman J. , Atkinson P.R. , Fraser J. , McCloskey R.
Published: May 2017

Introduction: Domestic violence (DV) rates in smaller cities have been reported to be some of the highest in Canada. It is highly likely that emergency department staff will come across victims of intimate partner violence (IPV) in their daily practice. Elsewhere we have found low rates of IPV documentation as well as underutilization of current tools in the ED. The purpose of this study is to describe ED staff awareness and knowledge surrounding IPV, currently accepted screening questions, and available screening tools. Methods: To assess awareness and knowledge, a cross-sectional online survey was distributed to ED staff (LPNs, NPs, Physicians, Residents, RNs) via staff email lists three times between July and October 2016, with a response rate of 45.9% (n=55). The primary outcomes were correct identification of appropriate IPV questions. Secondary outcomes included awareness of screening tools (HITS, WAST, PVS, AAS), whose role it is to question patients, and whether or not formal training has been received. Results: When asked to identify recommended questions for asking about IPV, staff were more likely to choose screening questions (75.3%; 95% CI 69.3% to 80.6%) compared to questions that are not recommended (23.8%; 95% CI 19.4% to 30.7%). However, 87.3% of respondents were not aware of current screening tools. 49.1% believed that all patients with typical injuries (ex. facial injury), should have further questioning about IPV, 20% believed that all patients with any injury, and 16.4% believed that all patients should be questioned about IPV. 89.1% also felt that it is both the physician and nurse’s role to question patients about IPV. Finally, 81.8% of ED staff did not receive any formal training on domestic or intimate partner violence. Conclusion: The present study indicates that there may be a gap in education surrounding this high risk condition as seen by the lack of knowledge surrounding current tools, lack of consensus on who should be questioned, and lack of training. Therefore, introduction of a knowledge translation piece may be beneficial to both ED physicians and nurses.