bluuebunny/crossref_metadata_2025 huggingface dataset:
LO82: Exploring eye-tracking technology to assess competency in point-of-care ultrasound
Authors: Lee W. , Chenkin J.
Published: May 2020

Introduction: Assessment of point-of-care ultrasound (POCUS) competency has been reliant on practical, visual and written examinations performed 1-on-1 with an examiner. These tools attempt to assess competency through subjective ratings, checklists and multiple-choice questions that are labour intensive using surrogate measures. Eye-tracking has been used on a limited basis in various fields of medicine for training and assessment. This technology explores visual processing and holds great promise as a tool to monitor training progress towards the development of expertise. We hypothesize that eye-tracking may differentiate novices and experts as they progress to become competent in interpretation of POCUS images and provide an objective measure in assessment of competency. Methods: Medical students, residents and attending physicians working in an academic emergency department were recruited. Participants viewed a series of 16 ultrasound video clips in a POCUS protocol for Focused Assessment using Sonography in Trauma (FAST). The gaze pattern of the participants was recorded using a commercially available eye-tracking device. The primary outcome was the gaze parameters including total gaze time in the area of interest (AOI), average time to fixation on the AOI, number of fixations in the AOI and average duration of first fixation on the AOI. Secondary outcome was the accuracy on the interpretation of the FAST scan. Results: Four novices and eight experts completed this study. The total gaze time in the AOI (mean +/- SD) was 76.72 +/- 18.84s among experts vs 53.64 +/- 10.33s among novices (p = 0.048), average time to fixation on the AOI was 0.561 +/- 0.319s vs 1.048 +/- 0.280s (p = 0.027), number of fixations in the AOI was 158.9 +/- 29.0 vs 121.8 +/- 17.5 (p = 0.042) and average duration of first fixation was 0.444 +/- 0.119s vs 0.390 +/- 0.024s (p = 0.402). The accuracy of the answers was 79.7 +/- 14.1% vs 45.3 +/- 21.9% (p = 0.007). Conclusion: In this pilot study, eye tracking shows potential to differentiate between POCUS experts and novices by their gaze patterns. Gaze patterns captured by eye tracking may not necessarily translate to cognitive processing. However, it allows educators to visualise the thought processes of the learner by their gaze patterns and provide insight on how to guide them towards competency. Future studies are needed to further validate the metrics for competency in POCUS applications.
LO83: Effect of the transition to an entrustability scale on assessor stringency and leniency on daily encounter cards in emergency medicine
Authors: Dewhirst S. , Cheung W. , Dudek N. , Wood T. , Frank J.
Published: May 2020

Introduction: Workplace based assessments (WBAs) are integral to emergency medicine residency training. However many biases undermine their validity, such as an assessor's personal inclination to rate learners leniently or stringently. Outlier assessors produce assessment data that may not reflect the learner's performance. Our emergency department introduced a new Daily Encounter Card (DEC) using entrustability scales in June 2018. Entrustability scales reflect the degree of supervision required for a given task, and are shown to improve assessment reliability and discrimination. It is unclear what effect they will have on assessor stringency/leniency – we hypothesize that they will reduce the number of outlier assessors. We propose a novel, simple method to identify outlying assessors in the setting of WBAs. We also examine the effect of transitioning from a norm-based assessment to an entrustability scale on the population of outlier assessors. Methods: This was a prospective pre-/post-implementation study, including all DECs completed between July 2017 and June 2019 at The Ottawa Hospital Emergency Department. For each phase, we identified outlier assessors as follows: 1. An assessor is a potential outlier if the mean of the scores they awarded was more than two standard deviations away from the mean score of all completed assessments. 2. For each assessor identified in step 1, their learners’ assessment scores were compared to the overall mean of all learners. This ensures that the assessor was not simply awarding outlying scores due to working with outlier learners. Results: 3927 and 3860 assessments were completed by 99 and 116 assessors in the pre- and post-implementation phases respectively. We identified 9 vs 5 outlier assessors (p = 0.16) in the pre- and post-implementation phases. Of these, 6 vs 0 (p = 0.01) were stringent, while 3 vs 5 (p = 0.67) were lenient. One assessor was identified as an outlier (lenient) in both phases. Conclusion: Our proposed method successfully identified outlier assessors, and could be used to identify assessors who might benefit from targeted coaching and feedback on their assessments. The transition to an entrustability scale resulted in a non-significant trend towards fewer outlier assessors. Further work is needed to identify ways to mitigate the effects of rater cognitive biases.
LO84: The incidence of fall-related intracranial bleeding in older adults taking anticoagulants, antiplatelets and neither medication: a meta-analysis
Authors: de Wit K. , Nishijima D. , Mason S. , Jeanmonod R. , Parpia S. , Varner C. , Mercuri M. , Kuczawski M. , Germini F. , Kagoma Y. , Mercier É.
Published: May 2020

Introduction: It is unclear whether anticoagulant or antiplatelet medications increase the risk for intracranial bleeding in older adults after a fall. Our aim was to report the incidence of intracranial bleeding among older adults presenting to the emergency department (ED) with a fall, among patients taking anticoagulants, antiplatelet medications, both medications and neither medication. Methods: This was a systematic review and meta-analysis, PROSPERO reference CRD42019122626. Medline, EMBASE (via OVID 1946 - July 2019), Cochrane, Database of Abstracts of Reviews of Effects databases and the grey literature were searched for studies reporting on older adults who were evaluated after a fall. We included prospective studies conducted in the ED where more than 80% of the cohort were 65 years or older and had fallen. We contacted study authors for aggregate data on intracranial bleeding in patients prescribed anticoagulant medication, antiplatelet medication and neither medication. Incidences of intracranial bleeding were pooled using random effect models, and I2 index was used to assess heterogeneity. Results: From 7,240 publication titles, 10 studies met inclusion criteria. The authors of 8 of these 10 studies provided data (on 9,489 patients). All studies scored low or moderate risk of bias. The pooled incidence of intracranial bleeding among patients taking an anticoagulant medication was 5.1% (n = 5,016, 95% Confidence Interval (CI): 4.1 to 6.3%) I2 = 42%, a single antiplatelet 6.4% (n = 2,148, 95% CI: 5.4 to 7.6%) I2 = 75%, both anticoagulant and antiplatelet medications 5.9% (n = 212, 95% CI: 1.3 to 13.5%) I2 = 72%, and neither of these medications 4.8% (n = 1,927, 95% CI: 3.5 to 6.2%) I2 = 50%. A sensitivity analysis restricted to patients who had a head CT in the ED reported incidences of 6.1% (n = 3,561, 95% CI: 3 to 8.3%), 8.4% (n = 1,781, 95% CI: 5.5 to 11.8%), 6.7% (n = 206, 95% CI 1.5 to 15.2%) and 6.6% (n = 1,310, 95% CI: 5.0 to 8.4%) respectively. Conclusion: The incidence of fall-related intracranial bleeding in older ED patients was similar among patients who take anticoagulant medication, antiplatelet medication, both and neither medication, although there was heterogeneity between study findings.
LO86: Lack of association between four biomarkers and the presence of persistent post-concussion symptoms after a mild traumatic brain injury
Authors: Le Sage N. , Le Sage N. , Frenette J. , Chauny J. , Berthelot S. , Archambault P. , Perry J. , Lee J. , Lang E. , McRae A. , Neveu X. , Tardif P. , Boucher V. , Mercier É. , Émond M.
Published: May 2020

Introduction: Mild Traumatic Brain Injury (mTBI) is a common problem: each year in Canada, its incidence is estimated at 500-600 cases per 100 000. Between 10 and 56% of mTBI patients develop persistent post-concussion symptoms (PPCS) that can last for more than 90 days. It is therefore important for clinicians to identify patients who are at risk of developing PPCS. We hypothesized that blood biomarkers drawn upon patient arrival to the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and the incidence of PPCS 90 days post mTBI. Methods: Patients were recruited in seven Canadian ED. Non-hospitalized patients, aged ≥14 years old with a documented mTBI that occurred ≤24 hrs of ED consultation, with a GCS ≥13 at arrival were included. Sociodemographic and clinical data as well as blood samples were collected in the ED. A standardized telephone questionnaire was administered at 90 days post ED visit. The following biomarkers were analyzed using enzyme-linked immunosorbent assay (ELISA): S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial fibrillary acidic protein (GFAP). The primary outcome measure was the presence of persistent symptoms at 90 days after mTBI, as assessed using the Rivermead Post-Concussion symptoms Questionnaire (RPQ). A ROC curve was constructed for each biomarker. Results: 1276 patients were included in the study. The median age for this cohort was 39 (IQR 23-57) years old, 61% were male and 15% suffered PPCS. The median values (IQR) for patients with PPCS compared to those without were: 43 pg/mL (26-67) versus 42 pg/mL (24-70) for S100B protein, 50 pg/mL (50-223) versus 50 pg/mL (50-199) for NSE, 2929 pg/mL (1733-4744) versus 3180 pg/mL (1835-4761) for c-Tau and 1644 pg/mL (650-3215) versus 1894 pg/mL (700-3498) for GFAP. For each of these biomarkers, Areas Under the Curve (AUC) were 0.495, 0.495, 0.51 and 0.54, respectively. Conclusion: Among mTBI patients, S100B protein, NSE, c-Tau or GFAP during the first 24 hours after trauma do not seem to be able to predict PPCS. Future research testing of other biomarkers is needed in order to determine their usefulness in predicting PPCS when combined with relevant clinical data.
LO88: S100B serum protein level for the detection of clinically significant intracranial hemorrhage in patients with mild traumatic brain injury: a prospective cohort study
Authors: Blais-L'Écuyer J. , Blais-L'Écuyer J. , Mercier É. , Tardif P. , Archambault P. , Chauny J. , Berthelot S. , Frenette J. , Perry J. , Stiell I. , Émond M. , Lee J. , Lang E. , McRae A. , Boucher V. , Le Sage N.
Published: May 2020

Introduction: Clinical assessment of patients with mTBI is challenging and overuse of head CT in the emergency department (ED) is a major problem. During the last decades, studies have attempted to reduce unnecessary head CTs following a mTBI by identifying new tools aiming to predict intracranial bleeding. S100B serum protein level might be helpful reducing those imaging since a higher level of S-100B protein has been associated with intracranial hemorrhage following a mTBI in previous literature. The main objective of this study was to assess whether the S100B serum protein level is associated with clinically important brain injury and could be used to reduce the number of head CT following a mTBI. Methods: This prospective multicenter cohort study was conducted in five Canadian ED. MTBI patients with a Glasgow Coma Scale (GCS) score of 13-15 in the ED and a blood sample drawn within 24-hours after the injury were included. S-100B protein was analyzed using enzyme-linked immunosorbent assay (ELISA). All types of intracranial bleedings were reviewed by a radiologist who was blinded to the biomarker results. The main outcome was the presence of clinically important brain injury. Results: A total of 476 patients were included. Mean age was 41 ± 18 years old and 150 (31.5%) were female. Twenty-four (5.0%) patients had a clinically significant intracranial hemorrhage while 37 (7.8%) had any type of intracranial bleeding. S100B median value (Q1-Q3) of was: 0.043 ug/L (0.008-0.080) for patients with clinically important brain injury versus 0.039 μg/L (0.023-0.059) for patients without clinically important brain injury. Sensitivity and specificity of the S100B protein level, if used alone to detect clinically important brain injury, were 16.7% (95% CI 4.7-37.4) and 88.5% (95% CI 85.2-91.3), respectively. Conclusion: S100B serum protein level was not associated with clinically significant intracranial hemorrhage in mTBI patients. This protein did not appear to be useful to reduce the number of CT prescribed in the ED and would have missed many clinically important brain injuries. Future research should focus on different ways to assess mTBI patient and ultimately reduce unnecessary head CT.
MP10: Does arrival pain severity predict stone characteristics or short-term outcomes in emergency department patients with acute renal colic?
Authors: Splinter G. , Gourlay K. , Hayward J. , Innes G.
Published: May 2020

Introduction: Renal colic is among the most painful conditions that patients experience. The main outcome determinants for patients with renal colic are stone size, location and hydronephrosis; however, little is known about the association of pain with these parameters. Our objective was to determine whether more severe pain is associated with larger stones, more proximal stones or more severe hydronephrosis, findings that might suggest the need for advanced imaging, hospitalization or early intervention. Methods: We used administrative data and structured chart review to study all adult emergency department (ED) patients in two cities with a renal colic diagnosis over one-year. Patients with missing imaging results or pain scores were excluded. Triage nurses recorded numeric rating scale (NRS) pain scores on arrival. We stratified patients into mild (NRS <4), moderate (NRS 4-7) and severe (NRS 8-10) pain groups, as per CTAS guidelines. Stone size (mm) and location (proximal, middle, distal ureter, or renal) were abstracted from imaging reports, while index admissions were determined from hospital discharge abstracts. We used multivariable linear regression to determine the association of arrival pain with stone characteristics and hydronephrosis severity (primary outcome), and we used multivariable logistic regression to determine the association of pain with index hospitalization (secondary outcome). We also performed a stratified analysis looking at ureteral vs. kidney (intrarenal) stones. Results: We studied 1053 patients, 66% male, with a mean age of 48 years. After controlling for patient and disease characteristics, we found no significant association between pain severity and stone size (b=−0.0004; 95%CI = -0.0015, 0.0008) or stone location (b = 0.0045; 95%CI: -0.020, 0.029). Nor did we find an association between pain and hydronephrosis severity (b = 0.016; 95%CI: -0.053, 0.022, p = 0.418). Stratified analyses using a Bonferroni correction for multiple comparisons revealed the same absence of associations in the kidney and ureteral stone subgroups. Arrival pain did not predict index admission (OR = 0.82, 95% CI: 0.59, 1.16). Conclusion: Arrival pain scores are not associated with stone size, stone location or hydronephrosis severity, and do not predict index visit hospitalization in ED patients with renal colic. Severe pain should motivate efforts to minimize treatment delays, but do not suggest the need to modify advanced imaging or admission decisions.
MP18: Pre-departure and post-elective requirements for global health electives: a survey of Canadian Royal College emergency medicine programs
Authors: Pritchard J. , Collier A. , Bartels S.
Published: May 2020

Introduction: Participation in Global Health (GH) electives can improve resourcefulness, cultural and ethical insight, and personal development. Risks to trainees, hosts and institutions may be minimized through pre-departure and post-elective training. In 2016 such training was mandatory in only 3 Canadian residency programs, however there is no published data specific to Canadian Emergency Medicine (EM) programs. This study sought to identify current GH elective requirements and related perceived gaps among Royal College EM programs. Methods: We conducted two cross-sectional surveys in 2019 (one each for Royal College EM PDs and residents) via email regarding training requirements for GH electives. Additionally, a survey link was distributed in the CAEP EM resident newsletter. We also contacted university PGME and/or global health offices to understand and collate university-wide requirements and resources. Results: Nine PDs responded, with 78% reporting having 1-5 residents participate in GH electives yearly. Many PDs were unsure of the requirements surrounding GH electives; two reported that pre-departure training was required, while none reported requiring post-departure debriefs. Overall, 67% of PDs felt that their residents were moderately prepared for GH electives and 33% felt they were unprepared to some degree. Thirty-three percent believed that improvements should be made to either pre-departure training or both pre- and post-departure training, while 56% were unsure if improvements were needed. Forty-seven out of an estimated 380 residents responded. Thirty-five percent of residents had completed a GH elective during residency. Of residents who participated in a GH elective, only one (6%) reported feeling very prepared; 18 residents (43%) reported there was a need to improve trainings. Residents reported a number of challenges during electives (lack of resources, inadequate supervision, safety issues) and identified priority topics for training. Conclusion: Although EM residents are participating in GH electives, the majority of EM residency programs do not require pre- or post-departure training. Some PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure/post-elective GH training or to encourage EM residents to access university-wide training.
MP19: Identifying and transmitting the culture of emergency medicine through simulation
Authors: Purdy E. , Alexander C. , Caughley M. , Bassett S. , Brazil V.
Published: May 2020

Introduction: Simulation is commonly used in medical education. It offers the opportunity for participants to apply theoretical knowledge and practice non-technical skills. We aimed to examine how simulation may also help to identify emergency medicine culture and serve as a tool to transmit values, beliefs and practices to medical learners. Methods: We undertook a focused ethnography of a simulated emergency department exercise delivered to 98 third-year medical students. This ethnography included participant-observation, informal interviews, and document review. Analysis was performed using a recursive method, a simultaneous deductive and inductive approach to data interpretation.We undertook a focused ethnography of a simulated emergency department exercise delivered to 98 third-year medical students. This ethnography included participant-observation, informal interviews, and document review. Analysis was performed using a recursive method, a simultaneous deductive and inductive approach to data interpretation. Results: All 20 staff (100%) and 92 of 98 medical students (94%) participated in the study. We identified 7 core values – identifying and treating dangerous pathology, managing uncertainty, patients and families at the center of care, balancing needs and resources at the system level, value of the team approach, education as integral, and emergency medicine as part of self-identity – and 27 related beliefs that characterized emergency medicine culture. We observed that culture was transmitted during the simulation exercise. Conclusion: This study contributes to the characterization of the culture of emergency medicine by identifying core values and beliefs that are foundational to the specialty. Simulation facilitated cultural compression which allowed for ready identification of values, beliefs and practices and also facilitated transmission of culture to learners. This study expands understanding of the culture of emergency medicine and the role of simulation in the process of cultural exchange.
MP20: Evaluation of the disruptors during advanced life support in emergency departments
Authors: Truchot J. , Michelet D. , Drummond D. , Plaisance P.
Published: May 2020

Introduction: Simulation is used as a teaching technique in the medical curriculum, and especially for advanced life support (ALS). However, simulated ALS can differ greatly from real life ALS. The aim of this exploratory study was to identify the different disruptors associated with real life ALS. Methods: We conducted a cross-sectional, anonymous, online survey that included 32 items. It was distributed by email to emergency physicians from five emergency departments in Paris. The aim of this online survey was to identify the elements perceived as disruptors during ALS. Other aspects of the survey explored the perceived differences between simulated ALS and real life ALS. Descriptive statistics of percentage, mean and standard deviation were used to analyse the data. Results: Among 100 surveyed physicians, 43 (43%) answers were analysed. 53% were women with a mean age of 32 ± 3 years old. The identified disruptors from real life ALS were task interruptions mainly from non-medical staff (n = 16; 37%), patient's siblings (n = 5; 12%), other specialists (n = 5; 12%) and the phone calls (n = 2; 5%). The situation of ED overcrowding (n = 12; 28%) was also mentioned as a potential disruptor. Overall, physicians reported that some technical and non-technical tasks were harder to perform in real life compared to simulated sessions. Conclusion: This exploratory study allowed the identification of disruptors encountered in real life cases of ALS, and may be used for future simulation-based teaching to enhance realism during sessions
MP24: Contagion: An innovative approach to learning the Orange Book and Choosing Wisely Canada guidelines around antimicrobial treatment
Authors: Khalid M. , Shah S. , Bala S. , Luterman M.
Published: May 2020

Innovation Concept: The Orange Book (OB) identifies drugs approved on the basis of safety and effectiveness by the FDA and serves as the gold standard reference for correct pharmacological therapies. It ties in closely with Choosing Wisely Canada (CWC) modelling good stewardship in antimicrobial prescriptions. The book focuses on passive didactic learning instead of active learning, which was shown to have a greater influence on prescribing behaviour. Educational video games, a form of active learning, have been shown to improve clinical skills in medical training. Contagion is a role-playing video game providing an active way of teaching antimicrobial components of the OB and CWC guidelines. Method: Phase I of Contagion was qualitatively tested on students and physicians at McMaster University for teaching effectiveness, applicability to real-life scenarios, and enjoyability. Post-game play 12 participants scored different aspects of the game on a Likert scale. Curriculum, Tool, or Material: The player is a rural physician treating infections in various communities. Each round, the player is given a crate of antibiotics. As communities are infected, the player is provided with clinical symptoms the patients present with. The player must identify the pathology and then correctly treat the communities. The player can treat empirically or order tests to identify the infectious organism. The player strategically navigates which communities to treat as there are limited actions per turn and the player must prevent communities from dying or infecting neighboring regions. Communities tend to build antibiotic resistance over time making first-line treatments unviable, thus careful strategizing and stewardship is essential. Active learning will occur when players are tasked with finding the correct answer to different presentations. After each turn, players will learn about the infecting organism, its phenotypes, and common infectious symptoms. This is considered passive learning. Conclusion: Contagion was well-received by physicians and medical students as an active learning tool to teach the OB and CWC guidelines. On preliminary user testing Contagion scored 5 in effectiveness in teaching treatments and 4.6 in teaching stewardship. An objective of this project is to perform large scale testing across schools to demonstrate the effectiveness of the learning components of the game. We hope to eventually create a tool that can be incorporated in continuing medical education for physicians.
MP25: Assessing the learning impact of the Northern City of Heroes public exhibit on bystander cardiopulmonary resuscitation response
Authors: Moskalyk M. , Ohle R. , Henson A. , McIsaac S. , Barriault C. , Doran B. , Martin N.
Published: May 2020

Innovation Concept: In Sudbury, ON 44% of out-of-hospital cardiac arrest (OHCA) patients receive bystander CPR (bCPR), and only 4.7% survive cardiac arrest. The Northern City of Heroes (NCH) community initiative was launched in April 2019 with a goal of improving survival from OHCA through hands-only bCPR in the municipality. One NCH initiative is an interactive exhibit at Science North, a science centre in Sudbury that hosts 250,000 visitors annually. The exhibit employs simulation trainers for CPR, accompanying signage and interactive elements. The goals of the exhibit are to activate bCPR, change and measure behaviours through exhibit interactions on how to deliver excellent CPR, and improve survival rates in OHCA patients. Methods: Data is being collected from 3000 visitors using self-reported surveying via SurveyGizmo to assess likelihood of performing bCPR, pre and post interacting with the exhibit. Visitor behaviour will be examined at the exhibit using video-recorded interactions and coding those behaviours using BORIS software. Behavioural data will be analyzed using the Visitor Engagement Framework (VEF) where initiation, transition and breakthrough learning-behaviours are coded and an exhibit Visitor Engagement Profile (VEP) is created. The VEF and VEP are tools used in informal learning settings to assess exhibit impacts on learning. Curriculum, Tool, or Material: The use of an easily-apprehendable, hands-on exhibit tool located in a public setting, such as a science centre, creates a platform for engaging large and diverse public audiences. This type of bCPR exhibitry has not been implemented in other similar environments. The informal learning setting allows the science centre staff to engage in personalized interactions that can solidify the quality of learning and confidence in employing the new skills developed. Conclusion: The NCH exhibit and new strategies for embedding informal curriculum are powerful tools to reach diverse audiences, build knowledge and skills, and have a measurable impact on bCPR and OHCA survival rates. Data is being captured and tracked by Health Sciences North around the City of Greater Sudbury's bCPR and OHCA survival rates to monitor long-term impacts of the NCH community initiatives. Limitations of the study may be found in the focused demographics as well as the nature of self-reported learning. Future research directions include broader geographical surveying to assess improvements in community response to OHCA as a direct result of an interactive bCPR exhibitry.
MP29: Using the Calgary audit and feedback framework to get the most out of physician practice reports
Authors: Dowling S. , Peterson A. , Wong C. , Cooke L. , Bond C.
Published: May 2020

Innovation Concept: The Calgary Audit and Feedback Framework (CAFF) is an innovative tool developed by the Physician Learning Program (PLP). By addressing four key factors –relationships, question choice, data visualization, and facilitation – CAFF addresses common barriers to physicians receiving their practice data. The goal of this study is to assess whether CAFF-facilitated physician performance improvement (PPI) sessions: 1) improve physicians’ receptiveness to their practice data, and 2) encourage physicians to both identify opportunities for practice change and create action plans. Methods: Peer facilitators were trained to facilitate PPI sessions using the CAFF model. In Calgary, 51/180 emergency physicians have attended at least one of the six PPI sessions. The sessions were evaluated using surveys, commitment to change forms, and the Feedback Orientation Scale (FOS). The FOS is a scale developed to measure a participant's orientation to performance feedback across the four domains of utility, accountability, social awareness, and feedback self-efficacy. Curriculum, Tool, or Material: The PLP has developed and implemented CAFF as a framework to help foster socially constructed learning in audit and group feedback sessions. The CAFF model ensures that the aforementioned four key factors are considered for design and implementation of audit and group feedback. The PLP found that establishing the meaning and credibility of the data is a necessary precursor to reflection and action planning. Conclusion: The FOS was completed for 25/32 physicians. The mean FOS score improved by 0.339 (p < 0.001; z=−3.863). While the mean scores all four domains increased, ‘Feedback Self-Efficacy’ increased the most by .0620 (p < 0.001; z=−3.999). Participants reported that examples of changes made by the peer facilitators were particularly helpful. Evaluations from the sessions suggested physicians overwhelmingly agreed or strongly agreed that the peer comparison was valuable, that the reports helped them reflect on their practice, and that the session helped them identify learning opportunities and strategies to change their practice.
MP36: Reducing utilization of unnecessary coagulation tests by emergency providers
Authors: Gupta R. , Mondoux S. , Rutledge G.
Published: May 2020

Background: Curbing unnecessary laboratory testing represents a significant opportunity for cost reduction in the Canadian health care system. A Choosing Wisely report cited a 31% decline in the number of tests ordered in a Canadian emergency department (ED) after implementation of recommendations. The international normalized ratio (INR) remains frequently ordered in emergency departments without an appropriate indication. Aim Statement: We aimed to reduce the number of INR tests completed in the St. Joseph's Healthcare Hamilton Emergency Department by 50% by April 30, 2019. Measures & Design: We conducted the study in an urban, academic ED employing the Epic electronic health record (EHR). We tailored interventions according to the Hierarchy of Effectiveness to address root causes revealed by analysis of our baseline ordering behaviour. Interventions included provider education around evidence-based ordering indications and removal of the INR from our “chest pain” bloodwork panel. Our outcome measure was the weekly number of INR tests completed per ED visit. Process measures included the proportion of INR tests ordered for inappropriate indications on monthly audits of 20 charts where an INR was completed. Balancing measures included average ED length of stay for patients receiving INR testing. Evaluation/Results: We collected outcome, process, and balancing measures through the EHR and analyzed this data using statistical process control charts. Over the nine-month study period, we decreased weekly INR tests from 248.4 to 115.0, a reduction of 56% which met criteria for special cause variation. This amounts to a cost savings of $43,008 per year. ED length of stay for patients receiving INR testing did not change significantly. Discussion/Impact: Our interventions were successful in realising our 50% target reduction in INR tests without an increase in ED length of stay from repeat venipuncture. This result is in keeping with similar efforts in other Canadian EDs. Our interventions could likely be spread to other settings where an INR is included as part of a “chest pain” panel. This may represent a substantial cost reduction opportunity on a national scale. Further work is needed in order to assess long term sustainability, which can be supported by employing high effectiveness mechanisms such as automation of optimal behaviour.
MP38: The impact of physician handoffs on the outcomes of emergency department patients: a medical administrative database retrospective cohort study
Authors: Mokhtari A. , Simonyan D. , Pineault A. , Mallet M. , Blais S. , Berthelot S.
Published: May 2020

Introduction: A physician handoff is the process through which physicians transfer the primary responsibility of a care unit. The emergency department (ED) is a fast-paced and crowded environment where the risk of information loss between shifts is significant. Yet, the impact of handoffs between emergency physicians on patient outcomes remains understudied. We performed a retrospective cohort study in the ED to determine if handed-off patients, when compared to non-handed-off patients, were at higher risk of negative outcomes. Methods: We included every adult patient first assessed by an emergency physician and subsequently admitted to hospital in one of the five sites of the CHU de Québec-Université Laval during fiscal year 2016-17. Data were extracted from the local hospital discharge database and the ED information system. Primary outcome was mortality. Secondary outcomes were incidence of ICU admission and surgery and hospital length of stay. We conducted multilevel multivariate regression analyses, accounting for patient and hospital clusters and adjusting for demographics, CTAS score, comorbidities, admitting department delay before evaluation by an emergency physician and by another specialty, emergency department crowding, initial ED orientation and handoff timing. We conducted sensitivity analyses excluding patients that had an ED length of stay > 24 hours or events that happened after 72 hours of hospitalization. Results: 21,136 ED visits and 17,150 unique individuals were included in the study. Median[Q1-Q3] age, Charlson index score, door-to-emergency-physician time and ED length of stay were 71[55-83] years old, 3[1-4], 48 [24,90] minutes, 20.8[9.9,32.7] hours, respectively. In multilevel multivariate analysis (OR handoff/no handoff [CI95%] or GMR[SE]), handoff status was not associated with mortality 0.89[0.77,1.02], surgery 0.95[0.85,1.07] or hospital length of stay (-0.02[0.03]). Non-handed-off patients had an increased risk of ICU admission (0.75[0.64,0.87]). ED occupancy rate was an independent predictor of mortality and ICU admission rate irrespectively of handoff status. Sensitivity and sub-group based analyses yielded no further information. Conclusion: Emergency physicians’ handoffs do not seem to increase the risk of severe in-hospital adverse events. ED occupancy rate is an independent predictor of mortality. Further studies are needed to explore the impact of ED handoffs on adverse events of low and moderate severity.
MP41: Crowdsourcing to save lives: A scoping review of bystander alert technologies for out-of-hospital cardiac arrest
Authors: Valeriano A. , Van Heer S. , Brooks S. , de Champlain F.
Published: May 2020

Introduction: Out-of-hospital cardiac arrest (OHCA) constitutes a significant global health burden, with a survival rate of only 10-12%. Early intervention is vital but limited by ambulance response times, low rates of bystander assistance, and access to AEDs. Smartphone technologies have been developed that crowdsource willing volunteers to nearby OHCAs in order to initiate resuscitation prior to ambulance arrival. We performed a scoping review to map the available literature on these crowdsourcing technologies and compared their key operational features. Methods: A search strategy was developed for five online databases: Medline, Cochrane, Embase, and Web of Science, as well as Google Scholar. We searched for primary studies and grey literature describing mobile phone technologies that alerted users of nearby cardiac arrests in the community. Two reviewers independently screened all articles and extracted relevant study information. Subsequently, we performed a search of the Google and Apple app stores, a general internet search, and consulted experts to identify all available technologies that might not be described in literature. We contacted developers for information on technology use and specifications to create a detailed features table. Results: We included 72 articles examining bystander alerting technologies from 15 countries worldwide, owing to the increasing importance of this topic. We identified 25 unique technologies, of which 18 were described in the included literature. Technologies were either text message-based systems (n = 4) or mobile phone applications (n = 21). Most (23/25) used global positioning systems to direct bystanders to victims and nearby AEDs. Response radii for alerts varied widely from 200m to 10km. Some technologies had advanced features such as video-conferencing with ambulance dispatch and detailed alert settings. Not all systems required volunteers to have first aid training. There were 18 studies examining effects on bystander intervention, all of which showed significant improvements using the technologies. However, only six studies assessed impact on survival outcomes. Key barriers discussed included false positive alerts, legal liability, and potential psychological impact on volunteers. Conclusion: Our review provides a comprehensive overview of crowdsourcing technologies for bystander intervention in out-of-hospital cardiac arrest. Future work in this growing field should focus on survival outcomes and methods of addressing barriers to implementation.
MP46: Clinically significant traumatic intracranial haemorrhage following minor head trauma in older adults: a retrospective cohort study
Authors: Mercier E. , O'Brien T. , Mitra B. , Le Sage N. , Tardif P. , Emond M. , D'Astous M.
Published: May 2020

Introduction: The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial haemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. Methods: This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. Results: From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). Conclusion: In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.
P010: An examination of sample size selection in medical record reviews in emergency medicine journals
Authors: Vinken J. , Bilic M. , Jones R. , Upadhye S.
Published: May 2020

Introduction: Medical record review (MRR) studies are commonly used in Emergency Medicine (EM) research. It is not always clear how sample size calculations are reported, or the methods by which they were derived. This scoping review sought to examine reporting and justification of MRR sample sizes from the EM literature. Methods: Using Web of Science, we identified the top ten journals, based on impact factor rating in 2018, within the field of Emergency Medicine. Journals were excluded if they were not in English or did not include sufficient articles for analysis. Within each of these ten selected journals, we searched for chart reviews and related terms: "medical record", "outpatient record", "inpatient record", "clinical record", and "nursing note". From this search subset, five articles were randomly selected from each journal. Data about sample size and sample size selection were extracted and analyzed by two reviewers independently for each article. Results: Of the 50 articles randomly selected, 48 articles were retrospective MRRs and two articles were prospective MRRs. 78% (39 articles) chose sample size based on availability, 14% (seven articles) chose sample size based on power calculations, 4% (two articles) chose sample size based on a previous study's methodology, and 4% (two articles) did not give details on sample size selection. Conclusion: While some emergency medicine MRRs based sample size selection on power or previous studies, the vast majority are based on availability with study-specific exclusion/inclusion criteria. This may indicate they are using a smaller sample size than necessary to be sufficiently powered to assess their end goal. More work is required to determine the effect of this on outcomes and interpretability of results, as well as which method is most accurate and efficient.
P014: Incidental findings in trauma whole-body CT scans: a systematic review
Authors: Tsang V. , Bao K. , Taylor J.
Published: May 2020

Introduction: Whole-body computed tomography scans (WBCT) are a mainstay in the work-up of polytrauma or multiple trauma patients in the emergency department. While incredibly useful for identifying traumatic injuries, WBCTs also reveal incidental findings in patients, some of which require further diagnostic testing and subsequent treatment. Although the presence of incidental findings in WBCTs have been well documented, there has been no systematic review conducted to organize and interpret findings, determine IF prevalence, and document strategies for best management. Methods: A systematic review was conducted using MEDLINE, PUBMED, and EMBASE. Specific journals and reference lists were hand-mined, and Google Scholar was used to find any additional papers. Data synthesis was performed to gather information on patient demographics, prevalence and type of incidental findings (IFs), and follow-up management was collected. All documents were independently assessed by the two reviewers for inclusion and any disagreements were resolved by consensus. Results: 1231 study results were identified, 59 abstracts, and 12 included in final review. A mean of 53.9% of patients had at least one IF identified, 31.5% had major findings, and 68.5% had minor findings. A mean of 2.7 IFs per patient was reported for articles that included number of total IFs. The mean age of patients included in the studies were 44 years old with IFs more common in older patients and men with more IFs than women. IFs were most commonly found in the abdominal/pelvic region followed by kidneys. Frequency of follow-up documentation was poor. The most common reported mechanisms of injury for patients included in the study were MVA and road traffic accidents (60.0%) followed by falls from >3m (23.2%). Conclusion: Although there is good documentation on the mechanism of injury, patient demographics, and type of IF, follow-up for IFs following acute trauma admission lacks documentation and follow-up and is an identified issue in patient management. There is great need for systematic protocols to address management of IFs in polytrauma patients.
P016: Feasibility of a nurse-led smoking cessation intervention in the emergency department
Authors: Tolmie A. , Erker R. , Donauer A. , Sullivan E. , Graham T. , Oyedokun T. , Stempien J.
Published: May 2020

Introduction: Cigarette smoking is a leading global cause of morbidity and mortality. Multiple studies internationally have established that cigarette smoking prevalence is higher in emergency department (ED) patients than their respective communities. Previously, we demonstrated the smoking prevalence among Saskatoon ED patients (19.6%) is significantly higher than the provincial average (15.1%), and over 50% of smoking patients would be receptive to ED-specific cessation support. The purpose of this project was to identify nurses’ beliefs regarding smoking cessation in the ED, and barriers to implementing it in the department. Methods: A questionnaire was administered to all nurses employed at St. Paul's Hospital ED in Saskatoon assessing attitudes towards ED cessations, as well as the benefit and feasibility of three potential interventions: brief cessation counselling, referral to community support programs, and distributing educational resources. The questionnaire included Likert scale numerical ratings, and written responses for thematic analysis. Thematic analysis was performed by creating definitions of identified themes, followed by independent review of the data by researchers. Results: 83% of eligible nurses completed the survey (n = 63). Based on Likert scores, ED nurses rarely attempt to provide cessation support, and would be minimally comfortable with personally providing this service. Barriers identified through thematic analysis included time constraints (68.3%), lack of patient readiness (19%), and lack of resources/follow-up (15.9%). Referral to community support programs was deemed most feasible and likely to be beneficial, while counselling within the ED was believed to be least feasible and beneficial. Overall, 93.3% of nurses indicated time and workload as barriers to providing ED cessation support during the survey. Conclusion: Although the ED is a critical location for providing cessation support, the proposed interventions were viewed as a low priority task outside the scope of the ED. Previous literature has demonstrated that multifaceted ED interventions using counselling, handouts, and referrals are more efficacious than a singular approach. While introduction of a referral program has some merit, having professionals dedicated to ED cessation support would be most effective. At minimum, staff education regarding importance of providing smoking cessation therapy, and simple ways to incorporate smoking cessation counselling into routine nursing care could be beneficial.