bluuebunny/crossref_metadata_2025 huggingface dataset:
P104: Can patients suffering traumatic cardiac arrest be identified using the National Ambulatory Care Reporting System (NACRS) database?
Authors: Radulovic N. , Kim A. , Evans C.
Published: May 2019

Introduction: Trauma is a common cause of mortality across all age groups and is projected to become the third greatest contributor to global disease burden. Recent studies have demonstrated that survival from traumatic cardiac arrest (TCA) is more favourable than once believed and further research on this population is being encouraged. Currently, it is unclear whether existing databases, such as the National Ambulatory Care Reporting system (NACRS), which includes all emergency department visits, could be used to identify TCAs for population-based studies. We aimed to determine the accuracy of NACRS administrative codes in identifying TCA patients. Methods: This retrospective validation study used data acquired from NACRS and our institutional Patient Care System. We identified a number of International Classification of Diseases, tenth revision (ICD-10) diagnostic, procedural and cause of injury codes that we hypothesized would be consistent with TCA. NACRS was subsequently searched for patients meeting the diagnostic code criteria (January 1 - December 31, 2015). The following inclusion criteria were: an eligible ICD-10 diagnostic code or a qualifying Canadian Classification of Health Interventions (CCI) procedure code and an eligible ICD-10 external cause of injury code. Electronic medical records for these patients were then reviewed to determine whether true TCAs had occurred. Results: Eighty-five patients met the inclusion criteria and one was excluded from analysis due to inaccessible health records, leaving 84 patients eligible for chart review. Overall, 55% (n = 46) of patients were found to have true TCA, 35% (n = 29) sustained a cardiac arrest of non-traumatic etiology and 11% (n = 9) were considered “unclear” (i.e. could not determine whether it was a true TCA based on the medical records). We found that true TCA patients were most accurately identified using a combination of ICD-10 CA cardiac arrest and external cause of injury codes (Positive predictive value: 70.6%, 95% CI 46.9-86.7). Conclusion: TCA patients were identified with moderate accuracy using the NACRS database. Further efforts to integrate specific data fields for TCA cases within existing population databases and trauma registries is necessary to facilitate future studies focused on this patient population.
P116: Impact of young age on outcomes of emergency department procedural sedation
Authors: Schlegelmilch M. , Roback M. , Bhatt M.
Published: May 2019

Introduction: Procedural sedation in the emergency department (ED) for children undergoing painful procedures is common practice, however little is known about sedation in very young children. We examined the effect of young age on sedation outcomes. Methods: This is a secondary analysis of an observational cohort study of children 0-18 years undergoing procedural sedation in six pediatric EDs across Canada. We compared presedation state, indication for sedation, medications, sedation efficacy and four main post-sedation outcomes (serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting) between patients who ≤2 years with those >2 years. Pre-sedation state, medications, indication for sedation and time intervals were summarized using frequency and percentage and compared with chi2 test. Logistic regression was used to examine associations between age group and outcomes. Results: 6295 patients were included; 5349 (85%) were >2 years and 946 (15%) were ≤2 years. Children ≤2 years were sedated most commonly for laceration repair (n = 450; 47.6%), orthopedic reduction (165; 17.4%) and abscess incision and drainage (136; 14.4%). Children >2years were sedated most commonly for orthopedic reductions (3983; 74.5%). Ketamine was the most common medication in both groups, but was used most frequently in children ≤2 years (80.9% vs 58.9%; p < 0.001). There was no difference in the incidence of SAE, significant interventions or oxygen desaturation between age groups, however children ≤2 years were less likely to vomit (Table 1). Young children had decreased odds of a successful sedation (OR 0.48; 95%CI: 0.37 to 0.63). On average, patients ≤2 years were sedated for 7 minutes less (74.1 vs 81.0 p < 0.001) and discharged 10 minutes sooner (90.1 vs 100.8 p < 0.001). Table 1 ≤2 years (n = 946) >2 years (n = 5349) OR (95%CI)* p-value n(%) n(%) Serious Adverse Event 8 (0.85) 59 (1.0) 0.76 (0.43-1.7) 0.477 Significant intervention 10 (1.0) 76 (1.4) 0.74 (0.34-1.4) 0.374 Oxygen Desaturation 50 (5.3) 303 (5.6) 0.93 (0.67-1.3) 0.640 Vomiting 14 (1.5) 314 (5.9) 0.24 0.13-0.41) <0.001 *Reference category: ≤2 years. Conclusion: Children ≤2 years most commonly received ED sedation for laceration repair using ketamine. Young age was not associated with a significant difference in SAEs, significant intervention or desaturation but was associated with decreased odds of vomiting and of successful sedation.
P119: Characteristics and outcomes of patients with neurologic complaints who leave the emergency department without being seen
Authors: Schouten A. , Gauri A. , Bullard M.
Published: May 2019

Introduction: Patients with neurologic chief complaints comprised 12.5% of total visits to the University of Alberta Emergency Department (ED) in 2017. Symptoms are often subjective, transient, or atypical, leading to diagnostic uncertainty. Serious diagnoses require timely intervention to mitigate morbidity and mortality, however the proportion of patients who leave the ED without being seen (LWBS) has increased over time. We sought to analyze the characteristics and outcomes of patients with neurologic complaints who LWBS to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care Reporting System database to select adult patients presenting to the University of Alberta Hospital in 2017 with neurologic complaints as defined by the Canadian Triage Acuity Scale (CTAS). Using standard descriptive statistics we examined demographic and clinical characteristics to compare LWBS patients to all others. Results: Of 8,726 total visits 7.54% patients LWBS. These patients tended to be younger on average (39 vs 55 years), with a larger proportion presenting at night (37.69%) and on Monday. The majority were triaged CTAS 3 (68.69%). Their mean length of stay was shorter than all other visits (3.70 vs 9.51 hours). Headache (22.74%), extremity weakness/symptoms of CVA (20.19%), head injury (14.32%), seizure (8.28%), and sensory loss/paresthesia (8.14%) comprised the top 5 neurologic complaints, and were disproportionately presented in LWBS patients; headache (31.76%), head injury (23.71%), sensory loss/paresthesia (12.01%), seizure (11.25%). Patients who LWBS also re-presented to the ED within 72 hours (21.43%), more often than those discharged by a physician (8.29%). Conclusion: Patients presenting with neurologic complaints who LWBS are younger, tend to arrive at night, with less acute presentations, however they more frequently return to the ED within 72 hours than those seen and discharged. Patients who LWBS may benefit from education, physician assessment or closer nurse reassessment at triage to increase the quality and safety of care in the ED, reduce return visits and ED utilization.
P121: Prehospital ultrasound use among Canadian aeromedical service providers – a cross-sectional survey
Authors: Sedlakova A. , Froh J. , Olszynski P. , Davis P.
Published: May 2019

Introduction: Evidence suggests that prehospital point of care ultrasound (POCUS) may improve outcomes. It serves as an aid in physical examination, triage, diagnosis, and patient disposition. The rate of adoption of POCUS among aeromedical services (AMS) throughout Canada is unknown. The objective of this study was to describe current POCUS use among Canadian AMS providers. Methods: This is a cross-sectional observational study. A survey was emailed to directors of government-funded AMS bases in Canada. Data was analyzed using descriptive statistics. Results: The response rate was 88.2% (15/17 AMS directors) and accounted for 42 out of 46 individual bases. POCUS is used by AMS in British Columbia, Alberta, Saskatchewan, and Manitoba. New Brunswick, Nova Scotia, Prince Edward Island, and Yukon are planning to introduce POCUS within the next year. Ontario, Quebec, and Newfoundland are not utilizing POCUS and are not planning to introduce it. BC is the only province currently using POCUS on fixed-wing aircraft. POCUS is used in <25% of missions, most frequently at sending hospital and in flight. Most useful applications were assessment for pneumothorax, free abdominal fluid, and cardiac standstill. Most common barrier to POCUS use was cost of training and maintenance of competence. Conclusion: Prehospital POCUS is available in Western Canada with one third of the Canadian population having access to AMS utilizing ultrasound. The Maritimes and the Yukon Territory will further extend POCUS use on fixed-wing aircraft. While there are barriers to POCUS use, those bases that have adopted POCUS consider it valuable.
P122: Narrative assessment of emergency medicine learners: What should we keep as we move to competency-based assessment?
Authors: Segeren S. , Shepherd L. , Pack R.
Published: May 2019

Introduction: For many years, Emergency Medicine (EM) educators have used narrative comments to assess their learners on each shift, either in isolation or combined with some type of Likert scale ranking. Competency based medical education (CBME), soon to be fully implemented throughout Canadian EM educational programs, encourages this type of frequent low-stakes narrative assessment. It is important to understand what information is currently garnered from existing narrative assessments in order to successfully and smoothly transition to the CBME system. The purpose of this study was to explore how one Canadian undergraduate EM program's narrative assessment comments mapped to two competency frameworks: one traditional CanMEDS-based and one competency-based, built on entrustable professional activities (EPAs). Methods: A qualitative and quantitative content analysis of 1925 retrospective, narrative assessments was conducted for the 2015/2016 and 2016/2017 academic years. The unprompted comments were mapped to the Royal College CanMEDS framework and the Association of Faculties of Medicine of Canada EPA Framework. Using an iterative coding process as per accepted qualitative methodologies, additional codes were generated to classify comments and identify themes that were not captured by either framework. Results: 93% and 85% of the unprompted narrative assessments contained comments that mapped to at least one CanMEDS role or EPA competency, respectively. The most common CanMEDS role commented upon was Medical Expert (86%), followed by Communicator, Collaborator and Scholar (all at 23%). The most common EPA competency mentioned related to history and physical findings (62%) followed by management plan (33%), and differential diagnosis (33%). However, 75% of narrative comments contained within the assessments, included ideas that did not fall into either framework but were repeated with frequency to suggest importance. The experiential characteristics of working with a learner were commented upon by 22% of preceptors. Other unmapped themes included contextual information, generalities and platitudes, and directed feedback for next steps to improve. Conclusion: While much of the currently captured data can be mapped to established frameworks, important information for both learner and assessor may be lost by limiting comments to the competencies described within a particular framework, suggesting caution when transitioning to a CBME assessment program.
P124: Canadian faculty experience of participating in a global health partnership working to build emergency medicine capacity in Ethiopia
Authors: Sithamparapillai A. , Fremes E. , Maskalyk J. , Landes M.
Published: May 2019

Introduction: Global health partnerships (GHPs) between high income and low income countries are a means of capacity building in education. Literature often focuses on the GHP structure and output, along with retention and experience of local trainees, but neglects the experience of involved faculty. Here, we survey Canadian teaching faculty participating in the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) to describe characteristics of participants and their experience in the program. Methods: EM faculty participating in TAAAC-EM teaching trips from 2011-2016 were invited to complete an online survey in February 2017. Teaching faculty travel for one month and undergo an extensive selection process, pre-departure training and post-trip debriefing. Quantitative and qualitative data were collected and analyzed using basic statistics and inductive thematic analyses respectively. Results: Overall, 19 (N = 30, 63.3%) faculty completed the survey, of which 13 had prior global health experiences (range 1 to > 12 months). On a scale of 1-7, participants rated their mean overall experience as a 5.9 and preparation as a 5.7. Among respondents, 79% would participate in future TAAAC-EM activities, 79% would engage in future global health endeavours, 95% said the experience improved their satisfaction of practicing clinical medicine and 89% said it improved their enjoyment of teaching medicine. However, while 58% stated they would recommend this experience without hesitation to colleagues, the remaining 42% said they would recommend this experience with caveats. This latter group had a lower rated preparedness (MD = 1.398, p = 0.003) and TAAAC-EM experience (MD = 1.545, p = 0.001). Major themes in qualitative responses included that the participants felt that intrinsic motivation and flexible predispositions were necessary to participate. Intrinsic motivation for global health involvement included appreciation and impact for GH, and personal growth. Regarding flexibility, respondents highlighted the importance of having a flexible demeanor to understand, accommodate and ethically address cultural differences and practicing in another context. Conclusion: The type of faculty to recruit for GHPs may require flexible predispositions and intrinsic motivation for GH. These qualities combined with adequate preparation can facilitate overall faculty experiences on global health trips.
P129: Safer transitions in the care of the elderly: identification of essential information in transitional care
Authors: Trivedi S. , Beckett S. , Dick A. , Hartmann R. , Roberts C. , Lyster K. , Stempien J.
Published: May 2019

Introduction: When presenting to the Emergency Department (ED), the care of elderly patients residing in Long Term Care (LTC) can be complicated by threats to patient safety created by ineffective transitions of care. Though standardized inpatient handover tools exist, there has yet to be a universal tool adopted for transfers to the ED. In this study, we surveyed relevant stakeholders and identified what information is essential in the transitions of care for this vulnerable population. Methods: We performed a descriptive, cross sectional electronic survey that was distributed to physicians and nurses in ED and LTC settings, paramedics, and patient advocates in two Canadian cities. The survey was kept open for a one month period with weekly formal reminders sent. Questions were generated after performing a literature review which sought to assess the current landscape of transitional care in this population. These were either multiple choice or free text entry questions aimed at identifying what information is essential in transitional periods. Results: A total of 191 health care providers (HCP) and 22 patient advocates (PA) responded to the survey. Within the HCPs, 38% were paramedics, 38% worked in the ED, and 24% were in LTC. In this group, only 41% of respondents were aware of existing handover protocols. Of the proposed informational items in transitional care, 100% of the respondents within both groups indicated that items including reason for transfer and advanced care directives were essential. Other areas identified as necessary were past medical history and baseline functional status. Furthermore, the majority of PAs identified that items such as primary language, bowel and bladder incontinence and spiritual beliefs should be included. Conclusion: This survey demonstrated that there is a need for an improved handover culture to be established when caring for LTC patients in the ED. Education needs to be provided surrounding existing protocols to ensure that health care providers are aware of their existence. Furthermore, we identified what information is essential to transitional care of these patients according to HCPs and PAs. These findings will be used to generate a simple, one page handover form. The next iteration of this project will pilot this handover form in an attempt to create safer transitions to the ED in this at-risk population.
P138: Management of opioid withdrawal: A qualitative examination of current practices and barriers to prescribing buprenorphine in a Canadian emergency department
Authors: Wiercigroch D. , Hoyeck P. , Sheikh H. , Hulme J.
Published: May 2019

Introduction: The opioid crisis persists, and in the context of this urgency and new practice guidelines, the practice of buprenorphine (BUP) prescription is expanding across Canadian emergency departments (EDs). The objective of this study was to identify current knowledge, attitudes and behaviours to managing opioid use disorder (OUD) in the ED, including barriers and facilitators to prescribing BUP. Methods: Forty ED staff physicians were randomly invited to participate from an urban Toronto ED which recently received continuing medical education in addictions, and whose hospital established an addictions follow-up clinic. Individual semi-structured interviews with the 19 physicians who self-selected to participate were grounded in phenomenology, allowing for in-depth accounts of participants’ lived experience and viewpoints on their role in addressing OUD. Thematic analysis was achieved through multiple readings; themes were coded using Dedoose software by two researchers. Themes were further organized as facilitators, barriers, and proposed solutions. Results: Opioid withdrawal management in the ED varied significantly between these practitioners in the same practice group. Facilitators to treating withdrawal and initiating BUP in the ED were rooted in three contributors to physician empowerment: knowledge about OUD and BUP, positive patient and provider experience with substitution therapy in the past, and exposure to physician champions to guide their practice. Systems-level facilitators included timely access to follow-up care and an available order set. Barriers included provider inexperience: missing subtle presentations of withdrawal, lacking feedback on treatment effectiveness, and reported uncertainty about the protocol from nursing staff. The ED environment also limits time to counsel effectively and discourages taking up a bed both to wait for withdrawal onset and for BUP induction. Other barriers were concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion: This is the first study describing barriers and facilitators to addressing OUD and prescribing BUP in the ED. These findings suggest a role for home induction, involvement of allied health professionals in BUP counseling, and heightened continuing medical education. Results will inform departmental efforts across Canada to implement BUP prescribing as standard of care for patients in opioid withdrawal.
P141: Identifying causes of delay in interfacility transfer of patients by air ambulance
Authors: Wong A. , McParland A. , Nolan B.
Published: May 2019

Introduction: Vast geography and low population density limit availability of specialized trauma and medical care in many areas of Ontario. As such, patients with severe illnesses often require a higher level of care than local facilities can provide and thus require an interfacility transfer to access tertiary or quaternary care. In Ontario, Ornge, a provincially run air ambulance, serves as the sole provider of air-based medical and critical care transport. Patient outcomes are impacted by the time to definitive care, yet little research about reasons for delay in interfacility transfer within Ontario has been conducted. This study aimed to identify causes of delay in interfacility transport by air ambulance in Ontario. Methods: Causes of delay were identified by manual chart review of electronic patient care records (ePCR). All emergent adult interfacility transfers for patients transported by Ornge between Jan. 1-Dec. 31, 2016 were eligible for inclusion. Patient records were flagged to be manually reviewed if they met one or more of the following criteria: 1) contained a standardized delay code; 2) the ePCR free text contained “delay”, “wait”, “duty-out”, or common misspellings therein; 3) were above the 75th percentile in total transport time; or 4) were above the 90th percentile in time to patient bedside, time spent at the sending hospital, or time to receiving facility. Each trip was categorized as having delays that fall into one or more of the following categories: time-to-sending delays, in-hospital delays, and time-to-receiving/handover delays. Results: Our search strategy identified 1,220 records for manual review and a total of 872 delays were identified. The most common delays cited included aircraft refuelling (234 delays); waiting for land EMS escort (144); and unstable patients requiring advanced care such as intubation, procedures, or transfusion (79). Other delays included handover or delays at the receiving facility (42); mechanical issues (36); dispatch-related issues (53); environmental hazards (43); staffing issues (47); and equipment problems (38). Conclusion: Some common causes of interfacility delay are potentially modifiable: better trip planning around refueling, and improved coordination with local EMS could impact many delayed interfacility trips in Ontario. Our analysis was limited by number and completeness of available records, and documentation quality. To better understand causes for delay, we would benefit from improved documentation and record availability.
P145: Orthomageddon: An epidemiological analysis of weather-dependent mass-casualty incidents in a Canadian city
Authors: Yeung M. , Schweitzer C. , Wang D. , Lang E.
Published: May 2019

Introduction: Unique weather patterns on March 16th, 2017 led to 3 times the number of emergency department (ED) visits due to fall-injuries (FIs) on snow or ice compared to winter averages. The objective of the study was to identify weather-dependent differences in demographics, length-of-stay (LOS) predictors, and volume of ED presentations for winter FIs. We placed emphasis on Chinook phenomenon (rapid freeze-thaw cycles) common east of the Rocky Mountains. Methods: Patients with extremity injury due to fall on snow or ice were identified from the Alberta Health Services ED database from November 1st 2013 to March 31st 2018. We conducted regressions, chi-square analysis, bivariate correlations, and t-tests to identify differences in post-Chinook, high-volume, and regular winter patient cohorts. High-volume dates included any date with more than 25 FI presentations, representing a 400% increase from the daily average of 5. Results: We identified 3478 patients, with females more likely to present, X2 (1, N = 3480) = 443.266, p < 0.001, making up 67.8% of the total cohort. Mean age was 48.2 (SD ± 19.9) in all patients, and 48.4 (SD ± 20.0) among the post-Chinook cohort. Looking at ED LOS in the full patient cohort, age over 65 predicted longer ED LOS (mean = 4.23, SD ± 3.06) compared to younger age groups (mean = 3.42, SD ± 2.39), t(3478) = -7.37, p < 0.001]. Patients with fractures to the wrist or hand had shorter ED LOS (mean = 2.50, SD ± 5.83) than those without (mean = 10.95, SD ± 92.54), t(3478) = 2.64, p = 0.008. Among admitted patients, results were similar, with elevated inpatient LOS for patients over the age of 65 (mean = 171.71, SD ± 508.35) compared to younger patients (mean = 45.45, SD ± 39.53), t(3478) = −3.41, p = 0.001. Patients with radius fractures had shorter LOS (mean = 61.87, SD ± 210.37) compared to those without (mean = 288.83, SD ± 632.29), t(3478) = 3.87, p < 0.001. With respect to volume and weather, night-freezing events (below-freezing temperatures the preceding day, followed by freezing temperatures prior to 0600 hours the following day) were more likely to result in high FI volume (OR, 8.08; 95% CI, 5.14, 12.07; p < 0.001) as were recent Chinook events (OR, 1.39; 95% CI, 1.06, 1.81; p = 0.017). Conclusion: Chinook-induced meteorological mass-casualty events can be severe, but do not target populations distinct from winter averages. They can be predicted based on forecasted weather variations and should be considered for population-level alerts utilizing cellular technology.
P148: Emergency physicians’ perception on engaging patients in their emergency department care
Authors: Krebs L. , Villa-Roel C. , Couperthwaite S. , Holroyd B. , Ospina M. , Rowe B.
Published: May 2019

Introduction: Patient engagement in health decision-making is an important research area within emergency medicine. Studies suggest that patients are often not highly engaged in care decisions, and may not be aware that there are decisions in which they can be involved. This study explored emergency physicians (EPs) perceptions of their patient engagement practices. Methods: As part of a stepped-wedge randomized controlled trial, an introductory seminar was held at 15 emergency department (ED) sites in Alberta. Seminars highlighted physician-patient communication and expectation gaps documented in local studies. As part of the seminar evaluation, EPs were asked to reflect on their engagement of patients in their practice. Descriptive results are reported. Results: A total of 114 EP surveys were returned. The majority of respondents were male (68%) and nearly 40% of respondents have practiced emergency medicine for 5 years or less. Less than half of the EPs (43%) reported always or usually asking their patients about their ED visit care expectations. Approximately one-third (32%) reported always or usually checking their patients’ understanding of management options (e.g., tests, treatments and/or procedures). Patients management preferences were always or usually elicited 24% of the time. Despite limited consistency in ascertaining patients’ preferences, 39% of EPs indicated that they always or usually considered their patients’ preferences when choosing a management plan. Half of the EPs (51%) reported that they always or usually involved their patients in decision-making. Yet, when asked whether other EPs involved their patients in decision-making, only 15% reported that they believed their fellow clinicians did this always or usually. On average, 68% of respondents believed their patients wanted to be completely or mostly involved in their ED and decision-making; however, 16% believed patients were actually completely or mostly involved in the ED care and decision-making. Conclusion: EPs agreed that patients want to be actively involved in their ED care decisions. Yet, their reflection on their own practice, and especially their perception of their colleagues’, highlight large gaps between physicians’ perception of what patients would like and what patients actually receive. Further research should explore these interactions in depth, understand what constrains EPs from involving patients and explore patient perceptions of these interactions.
PL04: Comparison of the cost and the quality of the care provided to low acuity patients in an emergency department and a walk-in clinic
Authors: Berthelot S. , Mallet M. , Simonyan D. , Guertin J. , Moore L. , Boilard C. , Boulet J. , Fortier C. , Olivier P. , Huard B. , Vachon K. , Lesage A. , Lévesque É. , Mokhtari A. , Baril L. , Yip O. , Bouchard M. , Létourneau M. , Pineault A. , Lafrenière M. , Blais S.
Published: May 2019

Introduction: Low acuity patients have been controversially tagged as a source of emergency department (ED) misuse. Authorities for many Canadian health regions have set up policies so these patients preferably present to walk-in clinics (WIC). We compared the cost and quality of the care given to low acuity patients in an academic ED and a WIC of Québec City during fiscal year 2015-16. Methods: We conducted an ambidirectional (prospective and retrospective) cohort study using a time-driven activity-based costing method. This method uses duration of care processes (e.g., triage) to allocate to patient care all direct costs (e.g., personnel, consumables), overheads (e.g., building maintenance) and physician charges. We included consecutive adult patients, ambulatory at all time and discharged from the ED or WIC with a diagnosis of upper respiratory tract infection (URTI), urinary tract infection (UTI) or low back pain. Mean cost [95%CI] per patient per condition was compared between settings after risk-adjustment for age, sex, vital signs, number of regular medications and co-morbidities using generalized log-gamma regression models. Proportions [95%CI] of antibiotic prescription and chest X-Ray use in URTI, compliance with provincial guidelines on use of antibiotics in UTI, and column X-Ray use in low back pain were compared between settings using a Pearson Chi-Square test. Results: A total of 409 patients were included. ED and WIC groups were similar in terms of age, sex and vital signs on presentation, but ED patients had a greater burden of comorbidities. Adjusted mean cost (2016 CAN$) of care was significantly higher in the ED than in the WIC (p < 0.0001) for URTI (78.42[64.85-94.82] vs. 59.43[50.43-70.06]), UTI (78.88[69.53-89.48] vs. 53.29[43.68-65.03]), and low back pain (87.97[68.30-113.32] vs. 61.71[47.90-79.51]). For URTI, antibiotics were more frequently prescribed in the WIC (44.1%[34.3-54.3] vs. 5.8%[1.2-16.0]; p < 0.0001) and chest X-Rays, more frequently used in the ED (26.9%[15.6-41.0] vs. 13.7%[7.7-22.0]; p = 0.05). No significant differences were observed in the compliance with guidelines on use of antibiotics in UTI and in the use of column X-Ray in low back pain. Conclusion: Total cost of care for low acuity patients is lower in walk-in clinics than in EDs. However, our results suggest that quality-of-care issues should be considered in determining the best alternate setting for treating ambulatory emergency patients.
LO11: Influence of fear of falling on return to emergency department and further falls in community-dwelling elderly presenting for minor trauma
Authors: Lanoue M. , Sirois M. , Worster A. , Perry J. , Lee J. , Daoust R. , Hegg S. , Carmichael P. , Émond M.
Published: May 2019

Introduction: According to WHO, one third of patients aged ≥65 fall every year. Those falls account for 25% of all geriatric emergency department (ED) visits. Fear of falling (FOF) is common in older patients who sustained a fall and is associated with a decline in mobility and health issues for patients. We hypothesized that there is an association between FOF and return to ED (RTED) and future falls. Objective: To assess the relation between FOF and RTED and subsequent falls in older ED patients Methods: This research was conducted as part of the Canadian Emergency Team Initiative in elderly (CETIe) multicenter prospective cohort study from 2011 to 2016. Participants: Patients 65 years or older were assessed and discharged from ED following a minor trauma. They had to be independent in all basic activities of daily living and being able to communicate in English or French. Measures: Primary outcome was RTED and secondary outcome was subsequent falls. Both were self-reported at 3 and 6 months. Patients were stratified according to Short Falls Efficacy Scale International (SFES-I) score, assessing FOF in different situations. A total score is calculated to determine the mild, moderate or severe level of FOF. Previous falls and TUG were used to evaluate patients’ mobility. OARS, ISAR and SOF were used to evaluated patient frailty. Descriptive statistical were performed and multiple regression were performed to show the association between SFES-1 score and outcomes. Results: FOF was measured in 2899 participants, of which 2214 participated at the 3 months follow-up and 2009 participated at the 6 months follow-up. Odds Ratio (OR) of return to ED at 3 months was 1.10 for moderate FOF and 1.52 for severe FOF (Type 3 test p = 0.11). At 6 months, OR was 1.03 for moderate FOF and 1.25 for severe FOF (Type 3 test p = 0.63). OR of subsequent fall at 3 months was 1.80 for moderate FOF and 2.18 for severe FOF (Type 3 test p < 0.001). At 6 months, OR of subsequent fall was 1.63 for moderate FOF and 2.37 for severe FOF (Type 3 test p < 0.001). Conclusion: The multicenter cohort study showed that severe fear of falling is strongly associated with subsequent falls over the next 6 months following ED discharge, but not significantly associated with return to ED episodes. Further research should be done to analyze the association between severe FOF and RTED.
LO14: Unrecognized delirium in a cohort of older ED patients assessed at a tertiary care center: signs of improvement?
Authors: Lee J. , Tong T. , Tierney M. , Kiss A. , Chignell M.
Published: May 2019

Introduction: BACKGROUND: Recognition rates of delirium in older ED patients were reported between 13 to 25% in studies conducted in the U.S in the 1990's. Recently, there has been increased attention to delirium in Emergency Medicine, with the development of Geriatric curriculums in Canada specifically focused on delirium. However rates of delirium recognition have not been reassessed in Canadian ED's. OBJECTIVES: To assess the rate of delirium recognition by ED staff in a cohort of older ED patients assessed at a tertiary care Canadian ED. Methods: STUDY DESIGN: Prospective observational cohort study at a Canadian teaching ED. PARTICIPANTS: Eligible patients were aged ≥70 years and older who had stayed in the ED for a minimum of 4 hours. We excluded patients who were critically ill, visually impaired or otherwise unable to communicate. DATA COLLECTION: Trained research assistants approached clinical staff prior to approaching patients to confirm that patients were delirium free. They then assessed demographics, ED length of stay (LOS) and cognition using the validated Montreal Cognitive Assessment scale (MOCA), mini-mental status exam (MMSE), delirium index and Richardson Agitation Scale (RASS) at baseline. Delirium was assessed using the validated Confusion Assessment Method (CAM). We report descriptive statistics and 95% confidence intervals (CI) where appropriate. Results: We enrolled 203 patients of which 102 (50.3%) were female. Their mean age was 81.0 years, mean LOS was 16.3 hours, mean MOCA was 23.4 and mean MMSE was 26.7. RA's detected delirium using the CAM in 16/203 patients (7.9%, 95% CI 4.6 to 12.5%). Mean MOCA and MMSE for delirious patients was 13.4 and 18.3 and their mean DI was 6.4. All CAM positive patients were deemed to be delirium free by clinical staff. RA alerted clinical staff in all cases where patients had delirium, but 3/16 were discharged home (18.8%, 95% CI 4.1 to 45.7%). Conclusion: Our findings confirm previous low delirium recognition rates in a Canadian Tertiary ED. Future research should explore barriers and facilitators to recognizing delirium in the ED.
LO30: Assessing screening tools to identify patients with palliative care needs in the emergency department: a systematic review
Authors: Kirkland S. , Garrido Clua M. , Kruhlak M. , Campbell S. , Villa-Roel C. , Rowe B.
Published: May 2019

Introduction: With an increasing proportion of patients in need of end-of-life (EOL) care presenting to the emergency department (ED), many of these patients may benefit from early palliative care (PC) referral. In fact, early PC referral is one of the Choosing Wisely ED recommendations in the USA. As such, there is a potential benefit to identifying patients with advanced or end-stage illness with PC needs. The objective of this systematic review is to identify and synthesize the available evidence regarding the existence and psychometric properties of screening tools to identify patients with advanced or end-stage illness and PC needs presenting to EDs. Methods: A comprehensive search of eight electronic databases and the grey literature was conducted. Studies assessing the ability of a screening instrument to identify ED patients with advanced or end-stage illness in need of PC were eligible for inclusion. Two independent reviewers completed study selection, quality assessment, and data extraction. Disagreements were resolved through third-party adjudication. Due to the significant heterogeneity, as well as inconsistent outcome reporting, a descriptive summary of the results was completed. Results: Once duplicates were removed, the title and abstracts of 3516 studies were screened, of which, 15 studies were included. Overall, 10 unique screening instruments were assessed across the studies. The most commonly assessed screening tool was the use of the modified surprise question (SQ), in which physicians were asked if they would be surprised if the patient died within a specified period of time. Only four of the included studies assessed the diagnostic or psychometric properties of the screening tools. One study reported that the modified SQ predicted PC consultation with 35% sensitivity, 89% specificity, and a negative predictive value of 97%. The proportion of patients identified with PC needs ranged from 12% to 73%, with studies utilizing the SQ reporting a range of 12% to 33%. Conclusion: A variety of screening tools are available to identify ED patients with advanced or end-stage illness who would benefit from a referral for PC. While the modified SQ was the most common instrument assessed and appears to be simple to implement, it is unclear if the diagnostic and psychometric properties of this tool are sufficiently robust to warrant widespread implementation.
LO32: A two-centre survey of caregiver perspectives on opioid use for children's acute pain management
Authors: Jun E. , Ali S. , Yaskina M. , Dong K. , Rajagopal M. , Drendel A. , Fowler M. , Poonai N.
Published: May 2019

Introduction: Given the current opioid crisis, caregivers have mounting fears regarding use of opioid medication in their children. Since caregivers are often the gatekeepers to their children's pain management, understanding their perspectives on analgesics is essential. For caregivers of children with acute injury presenting to the pediatric emergency department (PED), we aimed to determine caregivers’: a) willingness to accept opioids from emergency care providers, b) reasons for refusing opioids, and c) past experiences with opioids. Methods: A novel 31-item electronic survey was offered, via tablet device, to caregivers of children aged 4-16 years who had a musculoskeletal injury <7 days old and presented to one of two Canadian PEDs between March and November 2017. Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. Results: 517 caregivers completed the survey; mean age was 40.9 +/−7 years with 70.0% (362/517) being mothers. Children included 62.2% (321/516) males with an overall mean age of 10 +/−3.6 years. 49.6% of caregivers (254/512) reported willingness to accept opioids for moderate pain that persisted after non-opioid analgesia, while 37.1% (190/512) were unsure what they would do. Only 33.2% (170/512) of caregivers stated they would accept opioid analgesia upon discharge while 45.5% (233/512) were unsure about at-home use. Caregivers were primarily concerned about side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (OR 1.12, 95% CI 1.01-1.25) and side effects (OR 1.25, 95% CI 1.11-1.42) increased the odds of rejecting opioids in the emergency department, while fears of addiction (OR 1.19, 95% CI 1.07-1.32) and overdose (OR 1.15, 95% CI 1.04-1.27) increased the odds of rejecting opioids for at-home use. Conclusion: Only half of caregivers reported that they would accept opioids for moderate pain, despite ongoing pain following non-opioid analgesics. Caregiver fears of addiction, side effects, overdose, and masking their child's diagnosis influence their behaviours. These findings are a first step in understanding caregiver decision-making and can guide healthcare providers in their conversations about acute pain treatment with families.
LO38: Assessment of pain and provision of non-pharmacologic analgesia to children by prehospital providers in Southwestern Ontario: a cross-sectional study
Authors: Teefy J. , Mustafa H. , Poonai N. , VanAarsen K. , Dukelow A.
Published: May 2019

Introduction: There is abundant evidence that in children, assessment and pharmacologic treatment of pain by prehospital providers is suboptimal. Most paediatric calls are performed by primary care paramedics who are unable to administer pharmacologic analgesia to children but can administer non-pharmacologic therapies. We sought to describe the proportion of children provided non-pharmacologic analgesia by prehospital providers. Methods: We reviewed all ambulance call reports (ACR) of children age 0-17 years with an acutely painful condition (headache, abdominal pain, possible fracture, head/ears/eyes/nose/throat pain, back pain, and unclassified pain) who were transported to the Children's Hospital, London Health Sciences Centre between 2008 and 2017. We excluded ACRs lacking data pertaining to the primary outcome. Data collection was recorded by two blinded assessors using a study-specific ExcelTM sheet. The primary outcome was the proportion of children offered non-pharmacologic analgesia. We performed a hierarchical stepwise logistic regression on the primary outcome using covariates defined a priori: age, sex, visible deformity, documentation of pain score, and complaint. Results: Of 19782 ACRS, we report the preliminary results of 500 ACRs reviewed from Jan 1 to Feb 22, 2016. Of the 403 ACRs eligible for analysis, the median (IQR) age was 13 (8) years and 174 (43.2%) were females. 309/403 (76.7%) calls involved primary (as opposed to advanced) care paramedics. Pain assessments were performed in 171/403 (42.4%) calls, most commonly the 0-10 verbal numeric rating scale [128/171 (74.8%)] and the median (IQR) score was 7 (4) (n = 128). Non-pharmacologic analgesia was offered in 72/403 (17.9%) of calls, most commonly ice (37/72, 51%) and splint (29/72, 40%). In the multivariate model, significant predictors of non-pharmacologic analgesia included older age (OR 1.1; 95% CI: 1.1, 1.2; p = 0.01) and visible deformity (OR 8.2; 95% CI: 2.5, 30.2; p = 0.001). Sex (p = 0.62), documentation of pain score (p = 0.81), and complaint (p = 0.05) were not significant predictors. Conclusion: In this preliminary analysis, the provision of non-pharmacologic analgesia to children in Southwestern Ontario by prehospital providers was suboptimal despite moderate to severe levels of pain. Less than half of patients had pain assessments documented. There is a clear need for education surrounding pain assessment and non-pharmacologic analgesic options in children among prehospital providers.
LO45: Simulation-based research in emergency medicine in Canada: priorities and perspectives
Authors: Chaplin T. , Thoma B. , Petrosoniak A. , Caners K. , McColl T. , Forristal C. , Dakin C. , Deshaies J. , Raymond-Dufresne E. , Fotheringham M. , Ha D. , Holm N. , Huffman J. , Lonergan A. , Mastoras G. , O'Brien M. , Paradis M. , Sowers N. , Stern E. , Hall A.
Published: May 2019

Introduction: Simulation has assumed an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High quality simulation-based research (SBR) is required to ensure the effective and efficient use of this tool. This study sought to establish national SBR priorities and describe the barriers and facilitators of SBR in Emergency Medicine (EM) in Canada. Methods: Simulation leads (SLs) from all fourteen Canadian Departments or Divisions of EM associated with an adult FRCP-EM training program were invited to participate in three surveys and a final consensus meeting. The first survey documented active EM SBR projects. Rounds two and three established and ranked priorities for SBR and identified the perceived barriers and facilitators to SBR at each site. Surveys were completed by SLs at each participating institution, and priority research themes were reviewed by senior faculty for broad input and review. Results: Twenty SLs representing all 14 invited institutions participated in all three rounds of the study. 60 active SBR projects were identified, an average of 4.3 per institution (range 0-17). 49 priorities for SBR in Canada were defined and summarized into seven priority research themes. An additional theme was identified by the senior reviewing faculty. 41 barriers and 34 facilitators of SBR were identified and grouped by theme. Fourteen SLs representing 12 institutions attended the consensus meeting and vetted the final list of eight priority research themes for SBR in Canada: simulation in CBME, simulation for interdisciplinary and inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology. Conclusion: Conclusion: This study has summarized the current SBR activity in EM in Canada, as well as its perceived barriers and facilitators. We also provide a consensus on priority research themes in SBR in EM from the perspective of Canadian simulation leaders. This group of SLs has formed a national simulation-based research group which aims to address these identified priorities with multicenter collaborative studies.