bluuebunny/crossref_metadata_2025 huggingface dataset:
LO54: Emergency department prevalence of intracranial aneurysm on computed tomography angiography (EPIC-ACT)
Authors: Sheppard B. , Beller G. , O'Rielly C. , Wong Charles
Published: May 2020

Introduction: Evidence is accumulating that a CT plus a CT angiogram (CTA) of the head and neck may be adequate to rule out subarachnoid haemorrhage (SAH) in patients with a thunderclap headache, thus potentially negating the need for lumbar puncture. One of the most widely cited objections to this strategy is the fear of detecting “incidental asymptomatic aneurysms,” lesions seen on angiography that are not in fact the cause of the patient's symptoms. Currently existing data on the background rate of aneurysms are based on cadaveric studies, invasive angiography, or MRI, and thus does not reflect the true rate of incidental aneurysms that would be detected using a CT plus CTA strategy. This study characterizes the rate of incidental aneurysms identified on CTA in an emergency department population. Methods: In this multicentre retrospective cohort study we analyzed the electronic medical records of all emergency department patients ≥ 18 years of age who underwent CTA of the head and neck over a two month period across four urban tertiary care emergency departments. Two independent reviewers evaluated the final radiology reports and extracted relevant data. The primary outcome of interest was the presence of incidental intracranial aneurysm, defined as a newly diagnosed aneurysm not associated with evidence of acute hemorrhage. Secondary outcomes included aneurysm location and size. Results: Of 739 charts meeting inclusion criteria, incidental intracranial aneurysms were detected in 21 cases or 2.85% (95% confidence interval, 1.77 - 4.32). An additional 20 aneurysms were identified but excluded from the analysis as they were previously known (n = 9) or were associated with evidence of acute hemorrhage (n = 11) and thus were not considered incidental. Of 21 patients with identified incidental aneurysms, 7 had multiple aneurysms. The most common aneurysm sites were internal carotid artery (n = 13), middle cerebral artery (n = 6) and anterior cerebral artery (n = 4). The average size of incidental aneurysm was 4.1 mm. Conclusion: The rate of incidental intracranial aneurysm among emergency department patients undergoing CTA of the head and neck is lower than many previously described estimates obtained through invasive angiography and MRI studies. To our knowledge, this is the first study on the prevalence of incidental intracranial aneurysms in an emergency department specific population and may therefore help guide clinicians when considering using a CT plus CTA rule out strategy for patients presenting with acute headache suspicious for SAH.
LO58: Using volunteers to improve the experience of older patients in the emergency department
Authors: Ellis B. , Melady D. , Foster N. , Sinha S. , Lau V. , Saraga S. , McLeod S.
Published: May 2020

Introduction: The Maximizing Aging Using Volunteer Engagement in the ED (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program and the activities performed with older patients by its volunteers. Methods: The MAUVE + ED program was implemented in the ED (annual census 65,000) of a large academic tertiary hospital in Toronto, Ontario. Volunteers were trained to identify and approach older patients and others at greater risk for adverse outcomes, including poor patient experience, in the ED and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. Results: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median (IQR) time a MAUVE volunteer spent with a patient was 10 (5, 20) minutes, with a range of 1 to 130 minutes. The median (IQR) number of patients seen per shift was 7 (6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). Conclusion: Preliminary data suggest the MAUVE + ED volunteers were able to enrich the experience of older adults and their families/carers in the ED.
LO63: Evaluation of epinephrine secondary effects in a Canadian emergency department anaphylaxis adult cohort
Authors: Gabrielli S. , Ben-Shoshan M. , Lachance A. , Rhéaume M. , Londei-Leduc L. , Goldman R. , Chan E. , Upton J. , Hochstadter E. , Bretholz A. , O'Keefe A. , Chu D. , Morris J.
Published: May 2020

Introduction: There are few large-scale studies assessing the true risk of epinephrine use during anaphylaxis in adults. We aimed to assess the demographics, clinical characteristics, and secondary effects of epinephrine treatment and to determine factors associated with major and minor secondary effects associated with epinephrine use among adults with anaphylaxis. Methods: From May 2012 to February 2018, adults presenting to the Hôpital du Sacré-Coeur de Montréal (HSCM) emergency department (ED) with anaphylaxis were recruited prospectively as part of the Cross-Canada Anaphylaxis Registry (C-CARE). Missed cases were identified through a previously validated algorithm. Data were collected on demographics, clinical characteristics, and management of anaphylaxis using a structured chart review. Multivariate logistic regression models were compared to estimate factors associated with side effects of epinephrine administration. Results: Over a 6-year period, 402 adult patients presented to the ED at HSCM with anaphylaxis. The median age was 38 years (Interquartile Range [IQR]: 27, 52) and 40.4% were males. The main trigger for anaphylaxis was food (53.0%). A total of 286 patients (71.1%) received epinephrine treatment, of which 23.9% were treated in the pre-hospital setting, 47.0% received treatment in the ED, and 5.0% received epinephrine in both settings. Among patients treated with epinephrine, major secondary effects were rare (1.4% of patients), including new changes to electrocardiogram, arrhythmia, and neurological symptoms. Minor secondary effects due to epinephrine were reported in 50.0% of patients, mainly inappropriate sinus tachycardia (defined as a rate over 100 beats/minute in 30.1%). Major cardiovascular secondary effects were associated with regular use of beta-blockers (aOR 1.10 [95%CI, 1.02, 1.18]), regular use of ACE-inhibitors (aOR 1.16 [95%CI, 1.07, 1.27]), and receiving more than two doses of epinephrine (aOR 1.09 [95%CI, 1.00, 1.18]). The model was adjusted for age, history of ischemic heart disease, trigger of anaphylaxis, presence of asthma, sex, and reaction severity. Inappropriate sinus tachycardia was more likely in females (aOR 1.18 [95%CI, 1.04, 1.33]) and palpitations, tremors, and psychomotor agitation were more likely in females (aOR 1.09 [95%CI, 1.00, 1.19]) and among those receiving more than two doses of epinephrine (aOR 1.49 [95%CI, 1.14, 1.96]). The models were adjusted for age, regular use of medications, history of ischemic heart disease, triggers of anaphylaxis, presence of asthma, reaction severity, and IV administration of epinephrine. Conclusion: The low rate of occurrence of major secondary effects of epinephrine in the treatment of anaphylaxis in our study demonstrates the overall safety of epinephrine use.
LO65: Assessing opioid-prescribing patterns for low back pain patients before and after the implementation of clinician performance indicators in the emergency department
Authors: Yang F. , Dreyer J. , Van Aarsen K.
Published: May 2020

Introduction: Canada is in the midst of an opioid crisis. The number of apparent opioid-related deaths between January and March 2018 increased by 44% compared to the same period in 2016. The increasing use of prescription opioids and higher doses of opioids can lead to opioid addiction, toxicity and even death. Opioids are commonly prescribed for low back pain management in the ED, but the variability in opioid-prescribing patterns suggested an opportunity for improvement. Our centre implemented Clinician Performance Indicators (CPI) in 2015. CPIs were reported to each ED physician every 3 months and included the percentage of patients who were prescribed opioids. The intent was to raise awareness of opioid-prescribing patterns at our institution. Therefore, we evaluated opioid-prescribing patterns for patients with low back pain (LBP) before and after the CPI implementation. Methods: Data were obtained retrospectively for patients discharged from the ED from July 2015 to December 2018 with LBP-associated ICD 10 codes. We excluded admitted patients, those with specialist consultations, and patients who left without being seen. The primary outcome was opioid prescribing patterns for patients with LBP before and after CPI implementation. We performed a descriptive analysis of the data and compared the prescribing rates pre-implementation (July-Dec 2015) to post-implementation (July-Dec 2016) following a 6-month wash-out period. Moreover, we analyzed opioid-prescribing patterns over an extended period until December 2018. Results: After the exclusion criteria were applied, 8993 patients were included in the analysis. 53.5% were female and the mean (SD) age was 48.3 (19.78). During the three years of the study period, the percentage of LBP patients who received opioids showed a decreasing trend. Comparison of the pre and post CPI implementation periods showed a decrease in opioid prescriptions (42.0% vs 35.5%, 95%CI 2.9% to 10.2%). There was variation in opioids prescribed at our institution, the most common being hydromorphone (29.9%), followed by acetaminophen-oxycodone (24.2%) and acetaminophen-tramadol (20.0%). Conclusion: The implementation of CPIs positively impacted physicians' opioid-prescribing patterns for patients presenting with LBPs at our institution. Future studies are required to further improve the effectiveness of CPIs in influencing opioid-prescribing patterns.
LO76: Effect of task interruptions training on the quality of simulated ALS
Authors: Truchot J. , Michelet D. , Drummond D. , Freund Y. , Plaisance P.
Published: May 2020

Introduction: Task interruptions are reportedly frequent disturbances for emergency physicians performing advanced life support (ALS). The aim of this study was to evaluate the benefit of adding task interruptions in ALS simulated training session. Methods: We conducted a multi centered randomized controlled trial in four emergency departments of a university hospital in Paris, France. Each emergency team included one resident, one nurse and one emergency physician. The teams were randomized for the nature of their training session: control (without interruption) or realistic (with interruptions). The interruption consisted of an interfering family member speaking a foreign language, and of repetitive phone calls during ALS. After the first training session, teams were evaluated on a second realistic session with task interruptions. The primary outcome was non-technical skills assessed with the TEAM score during this evaluation session. We also measured the no flow time, and the Cardiff score, which reflects the quality of ALS: including chest compression depth and rate, no flow time. Results: On a total of 23 included teams, 12 had a control training session and 11 with task interruptions. Baseline characteristics and TEAM score were similar between the two groups (Mean difference: 3,3 [-2,2; 8,9]; p = 0,26). During the evaluation session, the TEAM score was lower for “realistic” teams (mean difference -8 [95% confidence interval -13; -3]). We also report a higher no flow time and similar overall Cardiff score. Conclusion: In this simulated ALS study, the presence of disturbances during simulation seemed to worsen the quality of training. This study highlights the negative consequences of task interruptions in emergency medicine.
LO78: Ready for launch? A survey of readiness factors among 2019 Competence By Design launch disciplines
Authors: Cheung W. , Hall A. , Dalseg T. , Oswald A. , Cook L. , Melle E. Van , Frank J.
Published: May 2020

Introduction: A critical component for successful implementation of any innovation is an organization's readiness for change. Competence by Design (CBD) is the Royal College's major change initiative to reform the training of medical specialists in Canada. The purpose of this study was to measure readiness to implement CBD among the 2019 launch disciplines. Methods: An online survey was distributed to program directors of the 2019 CBD launch disciplines one month prior to implementation. Questions were developed based on the R = MC2 framework for organizational readiness. They addressed program motivation to implement CBD, general capacity for change, and innovation-specific capacity. Questions related to motivation and general capacity were scored using a 5-point scale of agreement. Innovation-specific capacity was measured by asking participants whether they had completed 33 key pre-implementation tasks (yes/no) in preparation for CBD. Bivariate correlations were conducted to examine the relationship between motivation, general capacity and innovation specific capacity. Results: Survey response rate was 42% (n = 79). A positive correlation was found between all three domains of readiness (motivation and general capacity, r = 0.73, p < 0.01; motivation and innovation specific capacity, r = 0.52, p < 0.01; general capacity and innovation specific capacity, r = 0.47, p < 0.01). Most respondents agreed that successful launch of CBD was a priority (74%). Fewer felt that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). While most programs indicated that their leadership (94%) and faculty and residents (87%) were supportive of change, 42% did not have experience implementing large-scale innovation and 43% indicated concerns about adequate support staff. Programs had completed an average of 72% of pre-implementation tasks. No difference was found between disciplines (p = 0.11). Activities related to curriculum mapping, competence committees and programmatic assessment had been completed by >90% of programs, while <50% of programs had engaged off-service rotations. Conclusion: Measuring readiness for change aids in the identification of factors that promote or inhibit successful implementation. These results highlight several areas where programs struggle in preparation for CBD launch. Emergency medicine training programs can use this data to target additional implementation support and ongoing faculty development initiatives.
LO79: The variable landscape of resident selection: A study of Canadian Royal College emergency medicine training programs
Authors: Hale M. , Cheung W. , Frank J.
Published: May 2020

Introduction: Little is known about how Royal College emergency medicine (RCEM) residency programs are selecting their residents. This creates uncertainty regarding alignment between our current selection processes and known best practices and results in a process that is difficult to navigate for prospective candidates. We seek to describe the current selection processes of Canadian RCEM programs. Methods: An online survey was distributed to all RCEM program directors and assistant directors. The survey instrument included 22 questions consisting of both open-ended (free text) and closed-ended (Likert scale) elements. Questions sought qualitative and quantitative data from the following 6 domains; paper application, letters of reference, elective selection, interview, rank order, and selection process evaluation. Descriptive statistics were used. Results: We received responses from 13/14 programs for an aggregate response rate of 92.9%. A candidate's letter of reference was identified as the single most important item from the paper application (38.5%). Having a high level of familiarity with the applicant was considered to be the most important characteristic of a reference letter author (46.2%). Respondents found that providing a percentile rank of the applicant was useful when reviewing candidate reference letters. Once the interview stage is reached, 76.9% of programs stated that the interview was weighted at least as heavily as the paper application; 53.8% weighted the interview more heavily. Once final candidate scores are established for both the paper application and the interview, 100% of programs indicated that further adjustment is made to the rank order list. Only 1/13 programs reported ever having completed a formal evaluation of their selection process. Conclusion: The information gained from this study helps to characterize the landscape of the RCEM residency selection process. We identified significant heterogeneity between programs with respect to which application elements were most valued. Canadian emergency medicine residency programs should re-evaluate their selection processes to achieve improved consistency and better alignment with selection best practices.
LO93: A single center randomized control trial of intravenous lidocaine for the management of traumatic rib fractures
Authors: Patton P. , Vogt K. , Parry N. , Priestap F. , Ball I.
Published: May 2020

Introduction: Traumatic rib fractures (RF) are a common occurrence with 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and reducing morbidity and mortality. There is evidence of intravenous (IV) lidocaine's effectiveness and safety in the post-operative thoracic and abdominal surgical patient and we hypothesize that it may be ideal in trauma patients with RF. We evaluated IV lidocaine's analgesic efficacy in this population. Methods: A single-centre, double-blind, randomized control trial comparing a 72-96 hour IV lidocaine infusion plus standard analgesics to placebo infusion plus standard analgesics. Participants were adult trauma patients diagnosed with two or more RFs requiring hospital admission. A total of 36 patients were enrolled over 5 months in 2019. The study was powered to detect a 20% reduction in pain scores, which is determined to be clinically significant. Results: The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). There were consistent trends toward reduced VAS pain scores at rest and with movement in the lidocaine group as compared to placebo group with mean scores of 3.49 [SD 2.02 95% CI] and 7.08 [SD 1.71 95% CI] in the lidocaine group and 3.83 [SD 1.93 95% CI] and 8.03 [SD 1.44 95% CI] in the placebo group, at rest (p value 0.624) and with movement (p value 0.110), respectively . Secondary outcomes were patient satisfaction as measured on the VAS which demonstrated a score of 7.79 [SD 1.82 95% CI] in the lidocaine group and 6.63 [SD 1.77 95% CI] (p = 112) in the placebo group, and total morphine equivalents (ME) used (including breakthrough doses) that demonstrated a trend towards a reduction in the lidocaine group with 210.9 mg [SD 180.0 95% CI] compared to the placebo with total ME used of 309.9 mg [SD 221.8 95% CI]. Other secondary outcomes were protocol adherence, incidence of respiratory failure, hospital and ICU length of stay, mortality, incidence of lidocaine toxicity, and treatment regimens (non-opioid analgesics). Conclusion: These results demonstrate a trend towards lidocaine's analgesic benefit during rest and the critical times of patient movement and mobility, which has been demonstrated to be paramount in the reduction of respiratory complications from rib fractures. The results also tend towards a reduction in morphine equivalents, although the trial was not powered to demonstrate this
MP02: The impact of adoption of an electronic health record on emergency physician work: a time motion study
Authors: Calder-Sprackman S. , Clapham G. , Kandiah T. , Choo-Foo J. , Aggarwal S. , Sweet J. , Abdulkarim K. , Price C. , Thiruganasambandamoorthy V. , Kwok E.
Published: May 2020

Introduction: Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED). Methods: We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison. Results: All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99). Conclusion: Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.
MP03: Clearing the air: A retrospective cohort study of cannabis-related harms in urban Alberta emergency departments following legalization
Authors: Yeung M. , Weaver C. , Lang E. , Saah-Haines R. , Janz K.
Published: May 2020

Introduction: Non-medical cannabis recently became legal on October 18th, 2018 to Canadian adults. The impact of legalization on Emergency Departments (EDs) has been identified as a major concern. The study objective was to identify changes in cannabis-related ED visits and changes in co-existing diagnoses associated with cannabis-related ED visits pre- and post-legalization for the entire urban population of Alberta. Urban Alberta was defined as Calgary and Edmonton, inclusive of Sherwood Park and St. Albert given the proximity of some Edmontonians to their EDs) encompassing 12 adult EDs and 2 pediatric EDs. Methods: Retrospective data was collected from the National Ambulatory Care Reporting System, and from the HealthLink and the Alberta Poison and Drug Information Service (PADIS) public telehealth call databases. An interrupted time-series analysis was completed via segmented regression calculation in addition to incident rate and relative risk ratio calculation for the pre- and post-legalization periods to identify both differences among the entire urban Alberta population and differences among individuals presenting to the ED. Data was collected from October 1st, 2013 up to July 31st, 2019 for ED visits and was adjusted for natural population increase using quarterly reports from the Government of Alberta. Results: The sample included 11 770 pre-legalization cannabis-related visits, and 2962 post-legalization visits. Volumes of ED visits for cannabis-related harms were found to increase post-legalization within urban EDs (IRR 1.45, 95% CI 1.39, 1.51; absolute level change: 43.48 visits per month in urban Alberta, 95% CI 26.52, 60.43), and for PADIS calls (IRR 1.87, 95% CI 1.55, 2.37; absolute level change: 4.02 calls per month in Alberta, 95% CI 0.11, 7.94). The increase in visits to EDs equates to an increase of 2.72 visits per month, per ED. Lastly, increases were observed for cannabinoid hyperemesis (RR 1.23, 95% CI 1.10, 1.36), unintentional ingestion (RR 1.48, 95% CI 1.34, 1.62), and in individuals leaving the ED pre-treatment (RR 1.28, 95% CI 1.08, 1.49). Decreases were observed for coingestant use (RR 0.77, 95% CI 0.73, 0.81) and hospital admissions (RR 0.88, 95% CI 0.80, 0.96). Conclusion: Overall, national legalization of cannabis appears to be correlated with a small increase in cannabis-related ED visits and poison control calls. Post-legalization, fewer patients are being admitted, though cannabinoid hyperemesis appears to be on the rise.
MP06: Using electrocardiogram-to-activation time to assess emergency physicians’ diagnostic delay of acute coronary occlusion
Authors: McLaren J. , Chartier L.
Published: May 2020

Introduction: Electrocardiogram (ECG) diagnosis of acute coronary occlusion has been broadening in recent years, from classic ST-Elevation Myocardial Infarction (STEMI) criteria to STEMI-equivalents and rules for subtle occlusions. However, there is no quality metric focused on emergency physicians’ decision-making. We hypothesized that the time from initial emergency department (ED) ECG to activation of Code STEMI could quantify diagnostic delay associated with automated interpretation, classic STEMI criteria, and other signs of occlusion. Methods: This multi-centre retrospective study reviewed all ED Code STEMI patients with confirmed culprit lesions from two urban academic EDs over a three-year period (Jan 2016 to Dec 2018). We reviewed charts to calculate ECG-to-Activation (ETA) time, measured from the time stamp on the initial ED ECG to the time a Code STEMI was activated (based on the hospital call centre log). We examined ECGs to determine: 1) if automated computer interpretation labelled “STEMI” or not; and 2) whether they met classic STEMI criteria, STEMI-equivalent patterns, or rules for subtle occlusion, based on a priori criteria from published guidelines or studies. All ECGs were reviewed by the lead author (JTTM) and those not obviously meeting classic STEMI criteria were independently reviewed by the other author. Results: There were 180 Code STEMIs from the ED with culprit lesions, including 177 with complete information. Average ETA time was 46.5 minutes (95% Confidence Interval [CI] 36.3-56.7min). Automated interpretation labelled 55.4% of initial ECGs as “STEMI” (ETA 13.9 min, 95%CI 9.8-18.0min), and 44.6% not as “STEMI” (ETA 86.9min, 95%CI 67.9-105.9min). Initial ECGs included 62.1% with classic STEMI criteria (ETA 17.3min, 95%CI 12.8-21.8min), 11.3% with STEMI-equivalents (ETA 49.5min, 95%CI 29.5-69.5min), 18.1% with subtle occlusions (ETA 118.3min, 95%CI 81.5-155.1min) and 8.5% with no initial sign of occlusion (ETA 102.9min, 95%CI 53.9-151.9min). Inter-rater reliability was very good (Cohen's kappa 0.84). Conclusion: Over 90% of Code STEMI patients with culprit lesions had initial ECGs diagnostic of acute coronary occlusion, but automated interpretation and classic STEMI criteria only identified 55.4% and 62.1%, respectively. STEMI-equivalents and subtle occlusions were associated with significant diagnostic delays. ETA time can serve as a quality metric for emergency physicians and may help guide ED quality improvement initiatives.
MP08: Using administrative data to explore emergency department management of patients presenting with acute atrial fibrillation/flutter: Is Shock-First a more effective strategy than Drug-Shock?
Authors: Rowe B. , Bohlouli B. , Villa-Roel C.
Published: May 2020

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias managed in the emergency department (ED). Equipoise in cardioversion strategies for patients with recent onset AFF contributes to observed practice variation. Using administrative data, the objective of this study was to explore the pattern of practice and the comparative effectiveness (outcomes and costs) between Shock-First and Drug-Shock approaches in AFF. Methods: Adult patients >17 years of age with AFF from one academic Canadian hospital ED were eligible. Using administrative data linkage among the National Ambulatory Care Record System, provincial practitioner claims data repository and a local hospital pharmacy database, patients who received treatment with procainamide and/or electrical cardioversion for AFF were identified. Outcomes including disposition, length of stay, revisit within 72 hours and 30-days, and ED costs were analyzed over a seven-year period. Categorical variables are reported as percentages. Continuous variables are reported as median and interquartile range (IQR). Univariate and multivariate logistic regression analyses were completed and reported as odds ratios (OR) and 95% confidence intervals (CI). Results: Overall, 5,372 patients were identified with AFF; the median age was 70 years and 55% were male. The majority of patients had chronic or secondary AFF; however, in 1687 (31%) cardioversion options were employed for presumed were recent onset AFF. A Shock-First strategy was most common (1379 {82%}); 308 (18%) received a Drug-Shock approach. Discharge time was 33 minutes (95% CI: 4–63) longer in the Drug-Shock approach compared to the Shock-First approach. Hospital admissions were higher (OR = 2.33; 95% CI: 1.68, 3.24) and revisits within 30-days were lower (OR = 0.74; 95% CI: 0.54, 0.95) in the Drug-Shock group. The Shock-First strategy demonstrated marginally higher costs (median = $106 CND; 95% CI: $68.89, $144.40) in adjusted analyses. Conclusion: In patients with acute AFF, when cardioversion was attempted, a Shock-First strategy was employed 80% of the time and resulted in shorter ED length of stay and lower hospitalization; however, higher costs and ED revisits within 30-days were observed. Many factors, including physician and/or patient preferences, influence ED decision-making in patients with AFF and understanding the factors influencing these decisions requires further attention.
MP11: Emergency physician attitudes on opioid use disorder and barriers to providing buprenorphine/naloxone
Authors: Webster D. , Meyer T. , Crain C. , Fraser J. , Atkinson P.
Published: May 2020

Introduction: Buprenorphine/naloxone (buprenorphine) has proven to be a life-saving intervention amidst the ongoing opioid epidemic in Canada. Research has shown benefits to initiating buprenorphine from the emergency department (ED) including improved treatment retention, systemic health care savings and fewer drug-related visits to the ED. Despite this, there has been little to no uptake of this evidence-based practice in our department. This qualitative study aimed to determine the local barriers and potential solutions to initiating buprenorphine in the ED and gain an understanding of physician attitudes and behaviours regarding harm reduction care and opioid use disorder management. Methods: ED physicians at a midsize Atlantic hospital were recruited by convenience sampling to participate in semi-structured privately conducted interviews. Audio recordings were transcribed verbatim and de-identified transcripts were uploaded to NVivo 12 plus for concept driven and inductive coding and a hierarchy of open, axial and selective coding was employed. Transcripts were independently reviewed by a local qualitative research expert and themes were compared for similarity to limit bias. Interview saturation was reached after 7 interviews. Results: Emergent themes included a narrow scope of harm reduction care that primarily focused on abstinence-based therapies and a multitude of biases including feelings of deception, fear of diversion, feeling buprenorphine induction was too time consuming for the ED and differentiating patients with opioid use disorder from ‘medically ill’ patients. Several barriers and proposed solutions to initiating buprenorphine from the ED were elicited including lack of training and need for formal education, poor familiarity with buprenorphine, the need for an algorithm and community bridge program and formal supports such as an addictions consult team for the ED. Conclusion: This study elicited several opportunities for improved care for patients with addictions presenting to our ED. Future education will focus on harm reduction care, specifically strategies for managing patients desiring to continue to use substances. Education will focus on addressing the multitude of biases elicited and dispelling common myths. A locally informed buprenorphine pathway will be developed. In future, this study may be used to advocate for improved formal supports for our department including an addictions consult team.
MP13: Injuries presenting to the ED following jumps from bridges into water: a multi-agency retrospective case series
Authors: Stephanian D. , Shearer D. , Bandara N. , Brubacher J.
Published: May 2020

Introduction: Suicidal jumps from bridges into water are a unique blunt trauma mechanism. Impact into water produces substantial variation in injuries as compared to falls onto hard surfaces. Outcomes can be further complicated by submersion injuries. We identified cases through a multi-agency review in order to analyze injury patterns seen in EDs. Methods: Cases in British Columbia's Lower Mainland of jumps from bridges >12m into water between 2006 and 2017 were identified by retrospective review of Coast Guard and Police records. Records pertaining to identified incidents were located in ambulance and then hospital records. This multi-agency approach was necessary to generate a comprehensive case series, as case identification was not possible at the hospital level. Patient hospital charts were abstracted and injury incidence rates were analyzed. Results: Records were available for 41 of 52 patients. The population was 63% (26/41) male, median age 37 (IQR 29-48). Thirty-two cases were admitted to hospital, seven were deceased in the ED, one was discharged, and disposition is unknown for one. Most patients (85%) presented to Level One trauma centers. Bridge heights ranged from 15m to 70m; the mean fall height was 40.1m. Pulmonary injuries were nearly universal, including pneumothorax (51%), haemothorax (22%), and pulmonary infiltrate (34%). The primary cardiovascular concern was cardiac arrhythmia (51%). A quarter of cases had intraabdominal lacerations or ruptures (27%). Vertebral fractures at all levels were frequent (59%), although there was only one case each of cord transection and contusion. Neurological injuries were rare; 59% of patients presented to the ED with GCS ≥14 and the incidence of intracranial bleeding was low (7%). Rib fractures were commonly reported (37%) along with other fractures (32%). Body temperature was reported in 24 cases with 3 reports of moderate and 6 reports of mild hypothermia. Conclusion: This case series is the first to characterize injury patterns of jumps from bridges into water in Canada. Patterns are similar to reports in the literature from other countries. However, we found lower injury severity, and higher incidences of spinal fractures and cardiac arrhythmias. The low injury severity reflects the survivorship bias inherent to the sample: data was only obtained from patients who survived to be assessed the ED. These results suggest that patients with this mechanism of injury should be treated for both suspected trauma and cold-water immersion injuries.
MP15: Predictors of emergency department opioid use and variability of prescribing practices in a large multicenter Canadian cohort
Authors: Lau T. , Hayward J. , Innes G.
Published: May 2020

Introduction: Emergency department (ED) opioid prescribing has been linked to long-term use and dependence. Anecdotally, significant opioid practice variability exists between physicians and institutions, but this is poorly defined. Our objective was to collate and analyze multicenter data looking at predictors of ED opioid use and to identify potential areas for opioid stewardship. Methods: We linked administrative and computerized physician order entry (CPOE) data from all four ED's within our municipality over a one-year period. Eligible patients included those with a Canadian Triage and Acuity Scale (CTAS) pain complaint or an arrival numeric rating scale (NRS) pain score of greater than 3/10. Patients with missing demographic or chief complaint data were excluded. Multiple imputation was used for missing NRS pain scores. We performed descriptive analyses of opioid-treated and non-treated patients, followed by a multivariable logistic regression to identify predictors of ED opioid administration. Results: A total of 129,547 patients were studied. The mean age was 47.4 years and 55.4% were female. The median pain score was 6.6 in the no-opioid group and 8 in the opioid group. The most common pain categories were abdominal pain (23%), trauma (18.2%) and chest pain (15.3%). Overall, opioids were prescribed to 34% of patients. The most common CTAS score was CTAS 3 (44%), CTAS 1-2 42%) and CTAS 4-5 (13.9%). Multivariable predictors of opioid-use included the need for admission (adjusted OR 6.57; CI = 6.34-6.79), NRS pain score (aOR 1.24 per unit increase, CI 1.23-1.25), higher numerical CTAS score (aOR 0.89 per unit increase, CI 0.87-0.91), and chief complaints of back (aOR 7.69, CI 7.1-8.1), abdominal (aOR 5.9, CI 5.6-6.2), and flank pain (OR 3.8, CI 3.5-4). Oral opioids were prescribed in 39.8% of back pain presentations and 18.5% received IV opioids. Increasing age was a predictor but sex was not. There were significant institutional differences in opioid prescribing rates, with Hospital B being the least likely to prescribe opioids (aOR 0.82, CI 0.80-0.85) followed by Hospital C (aOR 0.83, CI 0.79-0.86) compared to the reference standard of Hospital A. Hospital D was most likely to prescribe opioids (aOR 1.32, CI 1.27-1.37). Conclusion: Predictors of ED opioid use were characterized using multicenter administrative data. Future research should seek to describe the physician- and site-level factors driving regional variation in opioid-based pain treatment.
MP26: The simulated newsroom: a novel educational intervention to teach advocacy skills to resident physicians
Authors: Bigham B. , Lavelle C. , Hulme J. , Hayman K.
Published: May 2020

Innovation Concept: Advocacy is a key competency of Canadian residency education, yet physicians seldom engage with supra-clinical advocacy efforts upon completion of training. Emergency medicine (EM) residency training may not equip graduates with the knowledge and skills required to engage as physician-advocates in their communities. Focused writing workshops may increase the confidence and ability of EM trainees to engage as health advocates. Methods: Following a literature review, simulated newsroom workshops were developed by two EM physicians with graduate-level journalism training and workplace experience. Participants were invited to participate in an audio-recorded focus-group and to submit their opinion editorial. Twelve participants registered for the workshops and six attended both sessions and the focus group; four submitted written work. Focus group transcripts and written work were qualitatively analysed to understand acceptability, feasibility, and how students might engage as future health advocates. Curriculum, Tool, or Material: The simulated newsroom consisted of participants acting as journalists and the expert facilitator acting as a news editor. The first workshop provided a framework for news judgement in a didactic session, followed by interactive exercises including: prioritization of news pitches, a simulated editorial meeting, and analysis of published news articles. The participants then drafted their own pitches for in situ feedback from peers and facilitators. Two-weeks later, participants brought their completed articles for peer and expert review before submitting their final article. Conclusion: The innovation bolstered resident physician confidence in advocacy through the popular press, and provided demonstrable skills in opinion writing. Participants felt challenged to develop compelling narratives and differentiate this form of advocacy communication from academic writing or prior media training. Participants valued the workshop as a voluntary component of residency education led by peer experts. Through their writing, residents demonstrated an understanding of structural factors that impact patient health and health systems. Future engagement as physician advocates may be tempered by fears of professional repercussions for public engagement; the impact of physician advocacy on population health outcomes is not yet known.
MP31: Optimizing ketorolac dosing by leveraging computerized order entry
Authors: Pompa N. , Bond C. , Wang D. , Dowling S.
Published: May 2020

Background: Ketorolac has long been used to manage pain in the Emergency Department and has the advantage of being the only parenteral NSAID formulation. Despite multiple studies demonstrating an analgesic ceiling dose of 10mg for intravenous ketorolac, higher doses (30-60mg) are commonly ordered. Use of optimal doses of ketorolac (10mg) has the advantage of lower side effects and cost. Aim Statement: The aim of this project was to increase the usage of the optimal dose parenteral ketorolac (10mg) without increasing the use of additional, concomitant or rescue opioids (balancing measures). Measures & Design: This pre-/post-intervention comparison study (May 1, 2016 to April 30, 2018) included all patients ≥18 years of age that received parenteral ketorolac at one of 4 EDs in the Calgary zone. All data was captured via administrative data records. Stakeholders (ED leadership, analgesia committee, nursing and pharmacy) provided feedback and support for the project. Our multi-modal intervention included modifying all ED computerized order sets such that the default parenteral ketorolac dose was 10mg (post-intervention) from 30mg (pre-intervention), education (dissemination of evidence to support the changes to clinicians) and our pharmacy securing 10mg vials of ketorolac. At their discretion, physicians’ were still able to order other doses of ketorolac. Evaluation/Results: During the 2 year study period, 19290 patient records were identified where parenteral ketorolac was administered during the ED visit. Baseline characteristics were similar between the pre/post periods. Prior to the change in default dosing, 10.5% of orders were for ketorolac 10mg compared to 87% in the post-intervention period (p < 0.000). Statistical process charts support the above results and demonstrate that the changes have been sustained. There were no differences in patients receiving ketorolac as the only analgesic between the pre/post periods (42% vs 42%, p = 0.396), nor where there significant changes in concomitant opioid usage (46% vs 46%, p = 0.817), or rescue analgesia (11% vs 12%, p = 0.097). Discussion/Impact: In this large cohort, our multi-modal intervention, resulted in a significant increase in optimal ketorolac parenteral dosing without a significant change in additional opioid use. The results support the utility of computerized order set changes as the cornerstone of an effective and rapid knowledge translation strategy to align physician practice with best evidence.
MP34: Block that Hip! Improving rates of ultrasound-guided fascia iliaca compartment blocks for hip fracture analgesia in the emergency department: a quality improvement initiative
Authors: Crickmer M. , Cameron A. , Smith D. , Ward S. , Wong A. , Wong K. , Cheng A. , Chu J. , Lockwood J. , Petrosoniak A. , Vaillancourt S.
Published: May 2020

Background: In patients with acute hip fracture, a fascia iliaca compartment block (FICB) has been shown to provide effective non-opioid analgesia, reduce the incidence of pneumonia, and potentially decrease the rate of delirium [1]. However, this procedure was infrequently used in the St. Michael's Hospital (SMH) emergency department (ED). Aim Statement: Our aim was to increase the proportion of patients with hip fracture receiving FICB in the ED to 50% in six months. Measures & Design: We completed two Plan-Do-Study-Act (PDSA) cycles, measuring rates of FICB before and after each cycle. The first was a departmental rounds presentation with information about the process and benefits of FICB, addressing barriers identified by surveying the group. The second cycle included a bundle of interventions comprising of an “instruction card” with the steps required to do the procedure, access to a video tutorial, and a list of experienced physicians willing to help less experienced providers perform FICB. Evaluation/Results: In the three months prior to the project, the rate of FICB in the ED was 12.5% (3/24). For the three months after the first PDSA cycle, the rate increased to 22.2% (8/36). Then, the second cycle was performed. In the following two months the rate further increased to 36.8% (7/19). Discussion/Impact: Despite the clear increase in FICB rate, these changes were not statistically significant (p = 0.063). Our methodology was shown to be safe and effective, and our model can be applied to other ED groups looking to increase their rates of FICB.