bluuebunny/crossref_metadata_2025 huggingface dataset:
MP35: Targeting the opioid crisis by influencing opioid prescribing in the emergency department
Authors: Shelton D. , Teo V. , Ding K. , Hefferon D.
Published: May 2020

Background: Liberal prescribing of opioids is a major contributing factor to the opioid crisis. Patients who take opioids for >5 consecutive days are at greater risk of long-term use. Evidence shows that significantly more opioids are prescribed for emergency department (ED) patients with acute pain compared to amounts consumed. Guidelines recommend prescribing a 3-day supply or 10-15 tablets of opioids for patients with acute pain Aim Statement: By January 2020, >70% of opioid prescriptions from our ED will be for <15 tablets of morphine 5 mg equivalents. Measures & Design: Emergency physicians were educated on best practice of prescribing opioids for discharged patients. An electronic prescription writer was built for discharged ED patients with a pop-up reminder for quantities >15 tablets (indicating a recommended quantity of 10-15 tablets) and a pop-up reminder for quantities >30 tablets (indicating a maximum quantity of 30 tablets and recommended quantity). A feature was built to auto-populate a prescription for morphine 5 mg po q4h prn x 10 tablets to facilitate adherence to guidelines. Outcome Measure % opioid prescriptions for <15 tablets of morphine 5 mg equivalents Process Measure Amount of opioids prescribed for discharged ED patients, measured as morphine 5 mg equivalents Number of opioid prescriptions for >30 tablets of morphine 5 mg equivalents Balancing Measure Number of patients that return to ED within 7 days and receive a repeat opioid prescription. Evaluation/Results: Prior to implementation of the electronic prescription writer a sample audit revealed that 50% of opioid prescriptions were written for <15 tablets of morphine 5 mg equivalents. For the first three quarters of 2019, 62%, 61% and 69% of opioid prescriptions were written for <15 tablets of morphine 5 mg equivalents. Only two prescriptions during the study period were for >30 tablets of morphine 5 mg equivalents. An average number of 7 patients per quarter were given a repeat opioid prescription during a return ED visit. Discussion/Impact: We were successful in influencing emergency physicians to prescribe fewer opioids to discharged patients. This has the potential to avoid converting ED patients with acute pain into long-term opioid users and to avoid the diversion of unused opioid tablets.
MP43: Evaluating factors related to quality of audio transmission during mandatory paramedic patches and technical barriers to efficient communication in the prehospital setting
Authors: Kelton D. , Doran S. , Davis M. , Van Aarsen K. , Momic J.
Published: May 2020

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. The quality and clarity of audio transmission is paramount for effective and efficient communication. The aim of this study was to examine the impact of audio transmission quality on the results of paramedic patch calls. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests exclusively for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Pre-specified patch audio quality metrics, markers of transmission quality and comprehension as well as the resulting orders from the BHP were extracted. Differences between groups was compared using chi-square analyses. Results: 214 records were identified and screened initially. 91 ACRs and audio records were included in the analysis. At least one explicit reference to poor or inadequate call audio quality was made in 55/91 (60.4%) of calls and on average, 1.4 times per call. Of the 91 audited call records, 48 of 91 (52.7%) patches experienced an interruption of the call. Each time a call was interrupted, re-initiation of the call was required, introducing a mean [IQR] delay of 81 [33-68] seconds to re-establish verbal communication. Order requests made by paramedics in calls with no interruptions were approved in 30 of 43 patches (70%) while those requests made in calls with one or more interruptions were approved in only 21 of 48 cases (44%) (Δ26.0%; 95%CI 5.6-43.5%, p = 0.01). Conclusion: This retrospective review suggests that audio quality and interruptions of patch calls may impact a physician's ability to approve orders for interventions in the prehospital setting. Focus on infrastructure and technology underlying this important mode of communication may be a fruitful avenue for future improvements in systems where this may be an issue.
MP49: Does reduced cough capacity in minor thoracic trauma leads to more atelectasis development?
Authors: Emond M. , Hegg S. , Thériault E.
Published: May 2020

Introduction: Minor thoracic trauma (MTI) accounts for approximately 15% of all injuries treated in the emergency department (ED). Many of which are minor and will be handle on an outpatient basis. MTI and rib fractures especially cause non-negligible pain. The pain experienced by patients can lead to reduce pulmonary function, decrease mucous clearance and decrease cough capacity leading in infectious problems and atelectasis. To our knowledge, there is no study of atelectasis development caused by reduced cough capacity in the setting of MTI. Objective: Evaluate if a variation in cough capacity leads to atelectasis development. Evaluate if there was a difference in cough capacity perception between the nurse, the physician and the patient himself. Methods: A prospective observational cohort study (2006-2012) in 4 ED recruited patients with a chief complaint of MTI, ≥ 16 years old, discharged home from the ED. Exclusion criteria: 1) a confirmed hemothorax, pneumothorax, fail chest, lung contusion or any other important thoracic or abdominal internal injury at the initial visit or unable to attend follow-up visits. Patients were assessed at 7- and 14- days. For each patient, age, sex, mechanism of injury, dyspnea, COPD/asthma and smoking status were collected. Chest x-ray was done at each visit; pulmonary complications were assessed by a blind radiologist. Cough capacity was assessed on a scale of 0 to 10 by a nurse, physician and patient himself at 0, 7- and 14- days. Pain was scored on a scale of 0 to 10. Chi -squared and odds ratio (IC: 95%. p ≤ 0.05) were assessed to determine if the cough capacity variation leads to atelectasis development. A Pearson correlation test was assessed the correlation in cough capacity among participants. Results: 1474 patients were recruited. Initial visit: 9% had atelectasis, 7 days: 7% and 4.6% at 14 days. 1105 patients were retained for analysis after exclusion of missing data. The median initial pain score was 7-8 for all patient categories. At 7 days, the odds ratio of atelectasis development were (score (0-3) 1.18 (0.42-3.34); score (4-7) 1.20 (0.48-3.03); p<=0.05). The Pearson correlation of cough capacity assessment, in patients without atelectasis were (0.53 nurse vs. patient; 0.37 physician vs. patient; 0.51 nurse vs. physician p<=0.05). As for the cough capacity perception correlation in patients with atelectasis were (0.62 nurse vs. patient; 0.40 physician vs. patient; 0.51 nurse vs. physician; p<=0.05). Conclusion: There is no statistically significant difference in atelectasis development depending on cough capacity and there is poor correlation regarding the perception of cough capacity except for the nurse. It would be interesting to develop a patient reported outcome measure questionnaire which targets minor thoracic trauma as it is a common emergency department complaint and it could help us improve medical management and patient quality of life
MP50: Vaping, tobacco and cannabis among patients presenting to the emergency department: a cross-sectional study
Authors: Zhou K. , Junqueira D. , Couperthwaite S. , Meyer J. , Rowe B.
Published: May 2020

Introduction: Inhaled toxins from tobacco smoking, cannabis leaf smoking as well as vaping/e-cigarette products use are known causes of cardio-respiratory injury. While tobacco smoking has decreased among Canadian adults, there are now several other forms of legal inhalant products. While legal, the evidence of benefit and safety of vaping is limited. Of concern, cases of e-cigarette or vaping products use associated lung injury (EVALI) have been accumulating in the U.S. and now in Canada. Despite this, very little is known about the inhalation exposure of emergency department (ED) patients; this study was designed to explore lung health in the ED. Methods: We investigated the prevalence of exposure to vaping, tobacco and cannabis among patients presenting to a Canadian ED from July to November 2019. Ambulatory (CTAS 2 to 5), stable, adult (≥ 17 years) patients were prospectively identified and invited to complete a survey addressing factors related to lung health (previous diagnosis of respiratory conditions and respiratory symptoms at the ED presentation) and information on current exposure to vaping, tobacco and cannabis smoking. Categorical variables are reported as frequencies and percentages; continuous variables are reported as medians with interquartile range (IQR). The study was approved by the Health Research Ethics Board. Results: Overall, 1024 (71%) of 1433 eligible patients completed the survey. The median age was 43.5 (IQR: 29, 60), and 51% were female. A total of 351 (31%) participants reported having been previously diagnosed with ≥1 respiratory conditions, and 177 (17%) were visiting the ED as a result of ≥1 respiratory symptoms (e.g., cough, shortness of breath, wheezing). Daily tobacco smoking was reported by 190 (19%), and 83 (8%) reported using vaping/e-cigarette products. Cannabis use within 30 days was described by 80 (15%) respondents. Exposure to tobacco and vaping products was reported by 39 (4%) participants, 63 (6%) reported using tobacco in combination with cannabis smoking, and 3% reported combining vaping and cannabis use. Conclusion: Patients seeking care in the ED are exposed to a large quantity of inhaled toxins. Vaping products, considered the cause of the most recent epidemic of severe lung injury, are used in isolation and in combination with other smoking products in Canada. These exposures should be documented and may increase the risk of lung health injuries and exacerbations of chronic respiratory conditions.
MP54: Management algorithm for the treatment of intoxications with calcium channel blockers: a simulation trial (MATRICS)
Authors: Gauvin V. , Raymond-Dufresne É. , St-Onge M.
Published: May 2020

Introduction: Cardiotoxicants poisonings are rare but have the potential to be highly lethal. Given the precarious nature of these poisonings, the Quebec Poison Control Center (CAPQ) has established a management protocol for optimal treatment. This study seeks to evaluate whether CAPQ's Calcium Channel Blocker (CCB) poisoning management protocol improves treatment delivery by physicians using simulation. The primary outcome is whether the management protocol decreases time to delivery of calcium and insulin. The secondary outcome is whether use of the management protocol increases appropriate dosing. Methods: For this randomized AB / BA crossover trial, Emergency Medicine and Internal Medicine residents were randomly assigned to one of two groups; one group received the management protocol during the simulation and the other did not. The crossover occurred 3-months later whereby the groups were reversed. Inverse probability weighting was used to compensate for losses at follow-up. Differences in baseline characteristics, as well as carry-over effect, were evaluated. The outcomes were analyzed with a two-level hierarchical model. Results: Twenty-three residents were included in the study. No significant differences in baseline characteristics were noted between the AB / BA groups, and no carry-over effect was identified on statistical analysis for all variables. As for the primary outcomes, time to administration of IV calcium decreased by 87 seconds (CI -266 to 92), time to insulin bolus decreased by 52 seconds (-217 to 114), and time to insulin infusion decreased by 115 seconds (-213 to -18) when the protocol was used. As for the secondary outcomes, there were no statistically significant differences for the percentage of adequate doses of IV calcium (RR: 1.27; 95% CI: 0.80–2.02), insulin bolus (RR: 1.30; 95% CI: 0.80–2.12) and insulin infusion (RR: 1.37; 95% CI: 0.99–1.91). Conclusion: This randomized cross-over study, which uses simulation to evaluate the performance of CAPQ's CCB poisoning management protocol, does not statistically demonstrate decreased time to administration or increased accuracy of dosing, due to the large confidence intervals. Unfortunately, we were not able to obtain the planned sample size due to limited participation. However, our results trend towards more optimal dosing and rapid dosing of treatments, and from a qualitative standpoint, the protocol appeared to increase the structure of patient care.
MP56: Intraosseous versus intravenous access in pediatric out-of-hospital cardiac arrest: an examination of prehospital vascular access methods and survival rates
Authors: Besserer F. , Dirk J. , Meckler G. , Tijssen J. , DeCaen A. , Kawano T. , Grunau B.
Published: May 2020

Introduction: Intraosseous (IO) and intravenous (IV) access to the vascular system for the delivery of fluid and medication is a component of advanced pediatric resuscitation. Data describing the use of IV or IO vascular access methods and outcomes of pediatric out-of-hospital cardiac arrest (OHCA) are limited. Methods: We analyzed prospectively collected data of non-traumatic OHCA of the Resuscitation Outcomes Consortium registry in Canada and the USA (2011-2015). We included patients 17 years of age and younger who were treated by emergency medical services (EMS). We described the vascular access routes utilized, and the success rate of these attempts. We performed a logistic regression model, to evaluate the association of vascular access route and survival, adjusting for age, sex, shockable initial rhythm, witnessed status, public location, EMS arrival interval and time from 911 call to vascular access. In this model, we excluded patients with failed, multiple site or no vascular access attempts during the resuscitation. Results: Of 1549 non-traumatic pediatric OHCA, 822/895 (92%) and 345/488 (71%) had successful IO and IV vascular access attempts, respectively. IO access was more common in younger cases. Of 761 cases included in the regression model, 30/601 (5%) of IO-treated cases survived to hospital discharge, in comparison to 40/160 (25%) of IV-treated cases. Intraosseous access was associated with a decreased survival to hospital discharge (adjusted OR 0.46; 95% CI 0.21 to 0.98). Conclusion: In pediatric patients with OHCA, intraosseous vascular access was more commonly successful than IV placement and more common among younger cases. However, in cases with successful vascular access, IO use was associated with lower survival to hospital discharge.
P002: Minimum archiving requirements for emergency medicine point-of-care ultrasound: a modified Delphi-derived national consensus
Authors: Wong M. , Woo M. , Cheung W. , Pageau P. , Olszynski P. , Lewis D.
Published: May 2020

Introduction: Point-of-care ultrasound (POCUS) has become standard practice in emergency departments ranging from remote rural hospitals to well-resourced academic centres. To facilitate quality assurance, the Canadian Association of Emergency Physicians (CAEP) recommends image archiving. Due in part to poor infrastructure and lack of a national standard, however, archiving remains uncommon. Our objective was to establish a minimum standard archiving protocol for the core emergency department POCUS indications. Methods: Itemization of potential archiving standards was created through an extensive literature review. An online, three-round, modified Delphi survey was conducted with the thirteen POCUS experts on the national CAEP Emergency Ultrasound Committee tasked with representing diverse practice locations and experiences. Participants were surveyed to determine the images or clips, measurements, mode, and number of views that should comprise the minimum standard for archiving. Consensus was pre-defined as 80%. Results: All thirteen experts participated fully in the three rounds. In establishing minimum image archiving standards for emergency department POCUS, complete consensus was achieved for first trimester pregnancy, hydronephrosis, cardiac activity versus standstill, lower extremity deep venous thrombosis, and ultrasound-guided central line placement. Consensus was achieved for the majority of statements regarding abdominal aortic aneurysm, extended focused assessment with sonography in trauma, pericardial effusion, left and right ventricular function, thoracic B-line assessment, cholelithiasis and cholecystitis scans. In total, consensus was reached for 58 of 69 statements (84.1%). This included agreement on 41 of 43 statements (95.3%) describing mandatory images for archiving in the above indications. Conclusion: Our modified Delphi-derived consensus represents the first national standard archiving requirements for emergency department POCUS. Depending on the clinical context, additional images may be required beyond this minimum standard to support a diagnosis.
P008: Care of palliative patients by paramedics in the 911 system
Authors: Wallner C. , Welsford M. , Lutz-Graul K. , Winter K.
Published: May 2020

Introduction: Palliative Care aims to relieve suffering and improve the quality of living and dying in patients with life-limiting, progressive conditions. Many patients and families prefer to stay at home at end of life. Despite this, many access 911 in times of apparent crisis. It has been noted in the literature that a well functioning palliative care system includes considering Emergency Medical Services as part of the patients’ circle of care. Training in palliative care is traditionally limited or absent for prehospital clinicians, including Paramedics and Emergency Medical Services Physicians. Furthermore, in our region, there are currently no medical directives available to Paramedics within the 911 system specifically addressing the needs of palliative care patients. Methods: A feasibility study (Expanding Care by Paramedics for Palliative Patients – EC3P) was designed to evaluate implementation of a new palliative care medical directive with trained teams of Paramedics available to respond to 911 calls. As part of this study, a pre-implementation retrospective chart review was performed. Patient care records were screened for “palliative” within the past medical history and text fields. Information about dispatch and scene times, patient demographics, details of patient encounter, and disposition of the patient were recorded. Descriptive statics were used. Results: Data was reviewed for all calls in 2018. Call data was reviewed to exclude those that were pediatric (<18yo) and those whose palliative status was unknown or unclear. There was a total of 318 calls. The majority of the calls (83%) were between 7am and 8pm, with peaks at 10 am and 6pm. The majority were transported to hospital (74%), 16% were transferred to hospital initiated by their palliative care physician, 20% “refused” transport, and 6% were declared dead and not transported. The most common reasons for calling 911 were new symptoms or a sudden worsening of chronic symptoms, followed by needs exceeding caregiver capacity; the third most common was lift assist without apparent injury. Conclusion: Much is unknown about the palliative patient population as it intersects with prehospital emergency care. This study will help provide information needed to guide further research and implementation.
P013: Emergency medicine in dental practice: shaping an educational curriculum
Authors: Vadeanu C. , Lobay K.
Published: May 2020

Introduction: There is increasing public demand for dentists and their professional regulators to mitigate medical risk to patients in private dental clinics – especially those that offer procedural sedation. Recent high-profile adverse events reported in the media suggest an urgent need to address this issue. However, there is a paucity of knowledge in the literature regarding how best to do so. We aim to explore opportunities for multidisciplinary emergency medical training of dentists, and to offer an informed perspective to assist with the preliminary development of a structured educational program. Methods: We employ Gioia Methodology, an established standard for inductive qualitative research and thematic analysis. Interviewees were recruited via email and selected to ensure a broad and knowledgeable perspective. We conducted individual semi-structured 1-hour interviews of 6 dentists, 4 medical anesthesiologists, 3 emergency physicians, and 1 oral and maxillofacial surgeon. Several interviewees had leadership roles in Canadian dental regulatory agencies and educational institutions. Data from these interviews was contemporaneously analyzed and organized into “first-order concepts”, “second-order themes” and “aggregate dimensions.” Results: Our findings demonstrated 12 first-order concepts. Dentists require "leadership from professional regulators", and "accreditation by recognized training institutions" to "ensure competence in initial emergency medical care of patients". "Customized training programs" led by "multidisciplinary instructors" – including emergency physicians – should ensure "pre-operative medical risk assessment", "appropriate intra-operative patient monitoring", and "the ability to recognize common medical emergencies". Emergency medical skills training should focus upon "teamwork within the office", "early activation of EMS", “ABC skills", and the administration of "emergency medications". Conclusion: Dentists require a very broad skillset to safely manage patients in their practice, especially when procedural sedation is required. Our aggregate dimensions provide an overview of our recommendations: we suggest that dentists must work with their regulators and educators to "build upon an existing culture of patient safety" by fostering "competence in the prevention, recognition and initial management of medical emergencies" in the dental practice setting.
P025: Checking the pulse in the 21st century: inter-observer reliability of carotid pulse detection by point-of-care ultrasound
Authors: Smith D. , Chenkin J. , Simard R.
Published: May 2020

Introduction: Detection of a pulse is crucial to decision-making in the care of patients who are in cardiac arrest, however, the current standard of manual pulse palpation is unreliable. An emerging alternative is the use of point-of-care ultrasound (POCUS) for direct assessment of the carotid pulse. The primary objective of this study is to determine the inter-observer reliability for healthcare provider interpretation of the carotid pulse by POCUS in patients who are peri-arrest or in cardiac arrest. Methods: We conducted a web-based survey of healthcare providers. Participants were shown a tutorial demonstrating POCUS detection of the carotid pulse and then asked to interpret 15 carotid pulse ultrasound clips from patients who were peri-arrest or in cardiac arrest. The primary outcome was inter-observer reliability for carotid pulse assessment. Secondary outcomes included inter-observer reliability stratified by healthcare provider role and POCUS experience, mean tutorial duration, mean pulse assessment duration, rate of pulse assessments < 10 seconds, and change in participant confidence before and after the study. Inter-observer reliability was determined by Krippendorff's α. Change in participant confidence was determined by Wilcoxon signed-rank test. Results: 68 participants completed our study, with a response rate of 75% (68/91). There was near perfect inter-observer reliability for pulse assessment amongst all study participants (α=0.874, 95% CI 0.869, 0.879). Senior residents (n = 24) and POCUS experts (n = 6) demonstrated the highest rates of inter-observer reliability, α=0.902 (95% CI 0.888, 0.914) and α=0.925 (95% CI 0.869, 0.972), respectively. All sub-groups had α greater than 0.8. Mean tutorial duration was 31 seconds (SD = 17.5) with maximum duration of 55 seconds. Mean pulse assessment duration was 7.7 seconds (SD = 5.2) with 76% of assessments completed within 10 seconds. Participant confidence before and after the study significantly increased from a median of 2 to a median of 4 on a 5-point Likert-type scale (z = 6.3, p < .001). Conclusion: Interpretation of the carotid pulse by POCUS showed near perfect inter-observer reliability for patients who were peri-arrest or in cardiac arrest. Participants required minimal training and indicated improved POCUS pulse assessment confidence after the study. Further work must be done to determine the impact of POCUS pulse assessment on the resuscitation of patients in cardiac arrest.
P032: Perceived versus actual cricothyroid membrane landmarking accuracy by emergency medicine residents and staff physicians
Authors: Schouela N. , Woo M. , Pan A. , Cheung W. , Perry J.
Published: May 2020

Introduction: Cricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. There is less data available about emergency physician performance. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models. Methods: Five male and female volunteers were selected as models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane. 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Data was gathered on each participant's perceived likelihood of success and attempt difficulty. Overall accuracy and accuracy stratified by sex and obesity status were calculated. Results: Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30-65%, p < 0.0001); and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12-51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI=−0.081-0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1-0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33). Conclusion: We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and longer time to secure the airway. Improved training techniques and a modified approach to cricothyrotomy may reduce failed attempts and improve the time to secure the airway.
P042: Workplace-based assessment in emergency medicine: how do physicians use entrustment anchors?
Authors: Robinson T. , Wagner N. , Szulewski A. , Dudek N. , Cheung W. , Hall A.
Published: May 2020

Introduction: Competency based medical education (CBME) has triggered widespread utilization of workplace-based assessment (WBA) tools in postgraduate training programs. These WBAs predominately use rating scales with entrustment anchors, such as the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). However, little is known about the factors that influence a supervising physician's decision to assign a particular rating on scales using entrustment anchors. This study aimed to identify the factors that influence supervisors’ ratings of trainees using WBA tools with entrustment anchors at the time of assessment and to explore the experiences with and challenges of using entrustment anchors in the emergency department (ED). Methods: A convenience sample of full-time emergency medicine (EM) faculty were recruited from two sites within a single academic Canadian EM hospital system. Fifty semi-structured interviews were conducted with EM physicians within two hours of completing a WBA for an EM trainee. Interviews were audio-recorded, transcribed verbatim, and independently analyzed by two members of the research team. Themes were stratified by trainee level, rating and task. Results: Interviews involved 73% (27/37) of all EM staff and captured assessments completed on 83% (37/50) of EM trainees. The mean WBA rating of studied samples was 4.34 ± 0.77 (2 to 5), which was similar to the mean rating of all WBAs completed during the study period. Overall, six major factors were identified that influenced staff WBA ratings: amount of guidance required, perceived competence through discussion and questioning, trainee experience, clinical context, past experience working with the trainee, and perceived confidence. The majority of staff denied struggling to assign ratings. However, when they did struggle, it involved the interpretation of WBA anchors and their application to the clinical context in the ED. Conclusion: Several factors appear to be taken into account by clinical supervisors when they make decisions regarding the particular rating that they will assign a trainee on a WBA that uses entrustment anchors. Not all of these factors are specific to that particular clinical encounter. The results from this study further our understanding on the use of entrustment anchors within the ED and may facilitate faculty development regarding WBA completion as we move forward in CBME.
P047: Emergency department practice patterns of UTI investigation among the delirious elderly: a retrospective chart review
Authors: Pinnell R. , Joo P.
Published: May 2020

Introduction: Delirium is a common emergency department (ED) presentation in elderly patients. Urinary tract infection (UTI) investigation and treatment are often initiated in delirious patients in the absence of specific urinary symptoms, despite a paucity of evidence to support this practice. The purpose of this study is to describe the prevalence of UTI investigation, diagnosis and treatment in delirious elderly patients in the ED. Methods: We performed a retrospective chart review of elderly patients presenting to the ED at The Ottawa Hospital between January 15-July 30, 2018 with a chief complaint of confusion or similar. Exclusion criteria were pre-existing and current UTI diagnosis, Glasgow Coma Scale <13, current indwelling catheter or nephrostomy tube, transfers between hospitals, and leaving without being seen. The primary outcome was the proportion of patients for whom urine tests (urinalysis or culture) or antibiotic treatment were ordered. Secondary outcomes were associations between patient characteristics, rates of UTI investigation, and patient outcomes. Descriptive values were reported as proportions with exact binomial confidence intervals for categorical variables and means with standard deviations for continuous variables. Comparisons were conducted with Fischer's exact test for categorical variables and t-tests for continuous variables. Results: After analysis of 1039 encounters with 961 distinct patients, 499 encounters were included. Urine tests were conducted in 324 patients (64.9% [60.6-69.1]) and antibiotics were prescribed to 176 (35.2% [31.1-39.6]). Overall 57 patients (11.4% [8.8-14.5]) were diagnosed with UTI, of which only 12 (21.1% [11.4-33.9]) had any specific urinary symptom. For those patients who had no urinary symptoms or other obvious indication for antibiotics (n = 342), 199 (58.2% [52.8-63.5]) received urine tests and 62 (18.1% [14.2-22.6]) received antibiotics. Patients who received urine tests were older (82.4 ± 8.8 vs. 78.3 ± 8.4 years, p < 0.001) but did not differ in sex distribution from those than those who did not. Additionally, patients who received antibiotics were more likely to be admitted (OR = 2.6 [1.48-4.73]) and had higher mortality at 30 days (OR = 4.2 [1.35-12.91]) and 6 months (OR = 3.2 [1.33-7.84]) than those who did not. Conclusion: Delirious patient without urinary symptoms in the ED were frequently investigated and treated for UTI despite a lack of evidence regarding whether this practice is beneficial.
P053: Adverse events and errors in trauma resuscitation: a systematic review
Authors: Nikouline A. , Quirion A. , Nolan B.
Published: May 2020

Introduction: Trauma resuscitations are plagued with high stress and require time sensitive and intensive interventions. It is a landscape that is a perfect hot bed for clinical errors and adverse events for patients. We sought to describe the adverse events and errors that occur during trauma resuscitation and any associated outcomes. Methods: Medline was searched for a combination of key terms involving trauma resuscitation, adverse events and errors from January 2000 to May 2019. Studies that described adverse events or errors in initial adult trauma resuscitations were included. Two reviewers analyzed papers for inclusion and exclusion criteria with a third reviewer for any discrepancies. Descriptions of errors, adverse events and associated outcomes were collated and presented. Results: A total of 3,462 papers were identified by our search strategy. 18 papers met our inclusion and exclusion criteria and were selected for full review. Adverse events and errors reported in trauma resuscitation included missed injuries, aspiration, failed airway, and deviation from protocol. Rates of adverse events and errors were reported where applicable. Mortality outcomes or length of stay were not directly correlated to adverse events or errors experienced in the trauma resuscitation. Conclusion: Our study highlights the predominance of adverse events and errors experienced during initial trauma resuscitation. We described a multitude of adverse events and errors and their rates but further study is needed to determine outcome differences for patients and possibility for quality improvement.
P077: Predicting positive practice improvement: a model for understanding how data and self-perception lead to practice change
Authors: Kamhawy R. , Chan T. , Mondoux S.
Published: May 2020

Introduction: Despite studies highlighting the inaccuracies of self-assessment, practicing physicians continue to rely on self-perception to maintain clinical competence. Many approaches have been proposed to augment physician performance. In the realm of Quality Improvement (QI), Audit and Feedback (A&F) has a modest effect. Educators have proposed coaching interventions and academic constructs have invoked training for early-career clinicians. Very few of these are driven by the perceptions and the needs of the end-user - the physicians. We currently lack a model to understand physicians’ perceptions of their own practice data and an understanding of the factors which would enable practice change. In this study, we sought to develop a model for data feedback which may best help physicians change practice. Methods: In a previous study, we conducted a needs analysis of 105 physicians in the Hamilton-Niagara area in order to understand which data metrics were most valuable to physicians. Using the survey results, we designed an interview guide that was used as a qualitative study of physicians’ perspectives on A&F. By intentional sampling, we recruited 15 physicians amongst gender groups, types of practice (academic vs community) and durations of practice. We conducted this interview with all 15 participants which were then transcribed. We then performed thematic analysis and extraction of all interviews using a realist framework. These were then translated into broader themes and, by using a grounded theory framework, created a model to understand how physicians relate practice data to their own sense of self. Interviews were anonymized and no identifying data was shared as part of the interview. All interviewees consented to participation at the outset and could withdraw at any time. Results: Via stakeholder interviews from 15 key informants, we developed a model for the understanding of how a physician's sense of self and the nature of the data (quantity and quality) may be combined to understand the likelihood of practice change and the adoption of the change strategy. Using this model, it is possible to understand the conditions under which A&F would provide the greatest opportunity for practice change. Conclusion: Physician identity intersects with A&F data to shed insights on practice improvement. Understanding the core identity constructs of different physician groups may allow for increased uptake in A&F processes.
P079: Clinical handover from emergency medical services to the trauma team: A gap analysis
Authors: Javidan A. , Nathens A. , Tien H. , da Luz L.
Published: May 2020

Background: Clinical handover between emergency medical services (EMS) and the hospital trauma team can be subject to errors that may negatively affect patient care. Thus far, there has been limited evaluation of the quality of EMS handover. As such, we sought to characterize handover practices from EMS to the trauma team, identify areas for improvement, and determine if there is a need for standardization of current handover practices. Aim Statement: Identify areas for improvement in handover from EMS to the trauma team, specifically examining handover content, structure, and discordances between different team members regarding handover expectations. Measures & Design: Data were prospectively collected over a nine week period by a trained observer at Canada's largest level one trauma centre. A randomized scheduled was used to capture a representative breadth of handovers. Data collected included outcome measures such as duration of handover, structure of the handover, and information shared, process measures such as questions and interruptions from the trauma team, and perceptions of the handover from nurses, trauma team leaders (TTLs) and EMS according to a bidirectional Likert scale. Evaluation/Results: Of 410 trauma team activations, 79 verbal handovers were observed. Information was often missing regarding airway (present 22%), breathing (54%), medications (59%), and allergies (54%). Handover structure lacked consistency beyond the order of identification and mechanism of injury. Only 28% of handovers had a dedicated question and answer period. Of all questions asked, 35% were questioning previously given information. EMS returned to categories of information unprompted in 84% of handovers. The majority of handovers (61%) involved parallel conversations between team members while EMS was speaking, which was associated with a greater number of interrupting questions from the trauma team (3.15 vs. 1.82, p =.001). There was a statistically significant disparity between the self-evaluation of EMS handovers and the perceived quality determined by nurses and trauma team leaders. Discussion/Impact: At our trauma centre, we have identified the need for handover standardization due to poor information content, a lack of structure and active listening, significant information repetition, and discordant expectations between EMS, nurses, and TTLs. We intend to use our results to guide the development of a co-constructed framework integrating the perspectives of all team members on the trauma team.
P085: Remember that patient you saw last week – Characteristics of patients experiencing unanticipated death following emergency department discharge
Authors: Hoang R. , Sampsel K. , Willmore A. , Yelle-Labre K. , Thiruganasambandamoorthy V. , Calder L.
Published: May 2020

Background: The emergency department (ED) is an at-risk area for medical error. We measured the frequency and characteristics of patients with unanticipated death within 7 days of ED discharge and whether medical error contributed. Aim Statement: This study aimed to calculate the frequency of patients experiencing death within 7 days after ED discharge and determine whether these deaths were related to their index ED visit, were unanticipated, and whether possible medical error occurred. Measures & Design: We performed a single-centre health records review of 200 consecutive cases from an eligible 458,634 ED visits from 2014-2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, or due to potential medical error. Reviewers performed content analysis to identify themes. Evaluation/Results: Of the 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges. We found 13 cases per 100,000 ED discharges were related and unanticipated deaths and 18 of these were due to potential medical errors. Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Patients experienced pneumonia (27.1%) as their most common cause of death. Patient characteristic themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, missed diagnosis. System themes included multiple ED visits or recent admission, no repeat vital signs recorded. Discussion/Impact: Though the frequency of related and unanticipated deaths and those due to medical error was low, these results highlight opportunities to potentially enhance ED discharge decisions. These data add to the growing body of ED diagnostic error literature and emphasize the importance of identifying potentially high risk patients as well as being cognizant of the common medical errors leading to patient harm.
P086: Violence prevention strategies in emergency departments: Key informant interviews
Authors: Stiphout M. , Tarraf R. , Fraser A. , Hair H. , Lang E. , Holroyd B. , Hastings S.
Published: May 2020

Introduction: Emergency Departments (EDs) are at high risk of workforce-directed violence (WDV). To address ED violence in Alberta Health Services (AHS), we conducted key informant interviews to identify successful strategies that could be adopted in AHS EDs. Methods: The project team identified potential participants through their ED network; additional contacts were identified through snowball sampling. We emailed 197 individuals from Alberta (123), Canada (46), and abroad (28). The interview guide was developed and reviewed in partnership with ED managers and Workplace Health and Safety. We conducted semi-structured phone interviews with 26 representatives from urban and rural EDs or similar settings from Canada, the United States, and Australia. This interview process received an ARECCI score of 2. Two researchers conducted a content analysis of the interview notes; rural and urban sites were analyzed separately. We extracted strategies, their impact, and implementation barriers and facilitators. Strategies identified were categorized into emergent themes. We aggregated similar strategies and highlighted key or unique findings. Results: Interview results showed that there is no single solution to address ED violence. Sites with effective violence prevention strategies used a comprehensive approach where multiple strategies were used to address the issue. For example, through a violence prevention working group, one site implemented weekly violence simulations, a peer mentorship support team, security rounding, and more. This multifaceted approach had positive results: a decrease in code whites, staff feeling more supported, and the site no longer being on union “concerned” lists. Another promising strategy included addressing the culture of violence by increasing reporting, clarifying policies (i.e., zero tolerance), and establishing flagging or alert systems for visitors with violent histories. Physician involvement and support was highly valued in responding to violence (e.g., support when refusing care, on the code white response team, flagging). Conclusion: Overall, one strategy is not enough to successfully address WDV in EDs. Strategies need to be comprehensive and context specific, especially when considering urban and rural sites with different resources available. We note that few strategies were formally evaluated, and recommend that future work focus on developing comprehensive metrics to evaluate the strategies and define success.
P099: Extending the trimodal distribution of death; trauma patients die at increased rates after discharge. Linking trauma registry data to vital statistics and hospital datasets identifies opportunities to save life
Authors: French J. , Somayaji C. , Dutton D. , Benjamin S. , Atkinson P.
Published: May 2020

Introduction: The New Brunswick Trauma Registry is a database of injury admissions from eight hospitals throughout the province. Data tracks individuals in-hospital. By linking this information with vital statistics, we are able to observe outcomes post-discharge and can model health outcomes for participants. We want to know how outcomes for trauma patients compare with the general population post discharge. Methods: Using data from 2014-15, we followed over 2100 trauma registry observations for one year and tracked mortality rate per 1,000 people by age-group. We also compared the outcomes of this group to all Discharge Abstract Database (DAD) entries in the province (circa. 7500 total). We tracked mortality in-hospital, at six months, and one year after discharge. We truncated age into groups aged 40-64, 65-84, and 85 or older. Results: In-hospital mortality among those in the trauma registry is approximately 20 per 1,000 people for those age 40-64, 50 per 1,000 people for those aged 65-84, and 150 per 1,000 people aged 85 or older. For the oldest age group this is in line with the expected population mortality rate, for the younger two groups these estimates are approximately 2-4 times higher than expected mortality. The mortality at six-month follow-up for both of the younger groups remains higher than expected. At one-year follow-up, the mortality for the 65-84 age group returns to the expected population baseline, but is higher for those age 40-64. Causes of death for those who die in hospital are injury for nearly 50% of observations. After discharge, neoplasms and heart disease are the most common causes of death. Trends from the DAD are similar, with lower mortality overall. Of note, cardiac causes of death account for nearly as many deaths in the 6 months after the injury in the 40 -64 age group as the injury itself. Conclusion: Mortality rates remain high upon discharge for up to a year later for some age groups. Causes of death are not injury-related. Some evidence suggests that the injury could have been related to the eventual cause of death (e.g., dementia), but questions remain about the possibility for trauma-mitigating care increasing the risk of mortality from comorbidities. For example, cardiac death, which is largely preventable, is a significant cause of death in the 40-64 age group after discharge. Including an assessment of Framingham risk factors as part of the patients rehabilitation prescription may reduce mortality.