bluuebunny/crossref_metadata_2025 huggingface dataset:
P042: Are we ready for a gunman in the emergency department? A qualitative study of staff perceptions of personal health risks, workplace safety, and individual and institutional readiness to respond to “code silver”
Authors: Dainty K. , Seaton M. , McGowan M. , Gray S.H.
Published: May 2017

Introduction: Hospital-based gun violence is devastatingly traumatic for everyone present and quite tragically on the rise. The Ontario Hospital Association (OHA) has recently designated active shooter situations as “Code Silver” and advised member hospitals to develop policies and train health care workers on how best to respond. Given that emergency departments (ED) are particularly susceptible to opportunistic breach by an active shooter and staff members are likely to be called upon as first responders, the impact of a Code Silver on ED functioning and staff members may be particularly severe. We hypothesized that there may not be a simple, one-size-fits-all-hospital-staff solution about how best to prepare ED physicians and staff to respond to a Code Silver situation. Methods: In order to inform and support future staff training initiatives related to Code Silver and other disaster situations in hospitals, we conducted a robust qualitative study to investigate perspectives and behaviour related to personal safety at work and Code Silver in particular among the multi-disciplinary ED staff at a single tertiary care centre in Toronto, Ontario. Participants for in-depth interviews and focus groups were recruited using a combination of stakeholder and maximum variation sampling strategies. Data analysis occurred in conjunction with data collection and standard thematic analysis techniques were employed. Results: Initial data analysis has revealed the following thematic concepts: the ubiquitous banality of personal health risk as an expected, acceptable feature of everyday life at work for ED staff, the perception of active shooters as a transgressive threat that violates the boundaries of professional responsibility, and the perceived fallacy of “readiness” to respond to disastrous situations. A fulsome analysis will be ready for presentation in June. Conclusion: Knowledge from this study indicates that ED staff members have unique and specific training needs in relation to an active shooter situation, and gives us deeper insight into potential areas of focus for training and opportunities for knowledge translation on the topic of Code Silver for EDs across the country.
P043: Outcomes associated with prehospital refractory ventricular fibrillation
Authors: Davis M. , Schappert A. , Chau B. , Leung A. , Van Aarsen K.
Published: May 2017

Introduction: When ventricular fibrillation (VF) cannot be terminated with conventional external defibrillation, it is classified as refractory VF (RVF). There is a paucity of information regarding prehospital or patient factors that may be associated with RVF. The objectives of this study were to determine factors that may be associated with RVF, the initial ED rhythm for patients with prehospital RVF, and the incidence of survival in patients who had RVF and were transported to hospital. Methods: Ambulance Call Records (ACRs) of patients with out of hospital cardiac arrest between Mar. 1 2012 and Apr. 1 2016 were reviewed. Cases of RVF (≥5 consecutive shocks delivered) were determined by manual review of the ACR. ED and hospital records were analyzed to determine outcomes of patients who were in RVF and transported to hospital. Descriptive statistics were calculated and all variables were tested for an association with initial ED rhythm, survival to admission, and survival to discharge. Results: Eighty-five cases of RVF were identified. A history of coronary artery disease (47.10%) and hypertension (50.60%) were the most common comorbidities in patients transported to the ED with RVF. Upon arrival to the ED, 24 (28.2%) remained in RVF, 38 (44.7%) had a non-shockable rhythm, and 23 (27.1%) had return of spontaneous circulation. Thirty-four (40%) survived to admission, while only 18 (21.2%) survived to discharge. Pre-existing comorbidities, time to first shock, time on scene, and transport time were not statistically associated with initial ED rhythm, survival to admission or discharge. Patient age was statistically associated with improved rhythm on ED arrival (p=0.013) and survival to discharge (58.24 yrs vs 67.40 yrs, Δ9.17, 95% CI 1.82 to 16.52, p=0.015). Conclusion: The majority of patients with prehospital RVF have a rhythm deterioration by the time care is transferred to the ED. Of these patients with a rhythm deterioration, few survive to hospital discharge. Younger patients are more likely to remain in RVF and survive to discharge. Further research is required to determine prehospital treatment strategies for RVF, as well as patient populations that may benefit from those treatments.
P046: The development of a validated checklist for bougie-assisted cricothyroidotomy
Authors: Dharamsi A. , Hicks C. , Sherbino J. , Gray S.H. , McGowan M. , Petrosoniak A.
Published: May 2017

Introduction: A cricothyroidotomy is a life-saving procedure and essential skill for EM physicians. The bougie-assisted cricothyroidotomy (BAC) is a newly describe technique that is both simple and reliable. There remains no consensus for the essential steps and ideal training strategy for the procedure. Using a modified Delphi process, we created an expert-derived checklist as a transferable educational tool for BAC instruction. Methods: A literature search was conducted to identify relevant articles describing the steps for BAC performance. These steps formed the first-iteration checklist for the modified Delphi process. Fourteen experts from general surgery, emergency medicine, otolaryngology, and anesthesia were recruited as participants for the Delphi process which consisted of three iterations. In the first two rounds, experts ranked each checklist step on a scale of 1-7, suggested additions, and provided comments. After each round the comments and rankings were integrated and steps with an average ranking of ≤3.0 were removed from the checklist for the next round. In the final round, consensus was sought by asking experts to indicate if this checklist was acceptable for teaching BAC to a novice learner. Results: A 22-item checklist was developed from a literature review. Following a modified Delphi methodology, the final BAC checklist contained 17 items. Internal consistency of the checklist was very good (α=0.855). In the third and final round, 86% of the participants agreed that the final iteration of the checklist. There was disagreement regarding “bougie hold up” as an appropriate method to confirm bougie position within the tracheal lumen. The checklist was modified, replacing “hold up” with digital palpation in the trachea as confirmation of successful bougie placement. With these modifications, consensus was achieved. Conclusion: Using a modified Delphi process, derived from existing literature and expert opinion, a 17-item BAC checklist was developed for novice instruction. This BAC checklist represents the first consensus-based set of steps for the procedure which may serve as a useful tool for trainee instruction and evaluation. Future research is required to test the validity of this checklist in training for a BAC and its applicability within competency-based medical education.
P047: Test characteristics of point of care ultrasound for the diagnosis of retinal detachment in the emergency department
Authors: Docherty G. , Francispragasam M. , Silver B. , Prager R. , Maberley D. , Lee D. , Kim D.J. , Albiani D. , Kirker A. , Andrew M.
Published: May 2017

Introduction: The acute onset of flashes and floaters is a common presentation to the emergency department (ED). The most emergent etiology is retinal detachment (RD), which requires prompt ophthalmologic assessment. Previous studies of point of care ultrasound (POCUS) have reported high sensitivity and specificity for RD, but are limited by small sample size, use of highly trained and experienced sonographers, and referral bias. Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. Methods: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of ED patients presenting with the complaint of flashes or floaters in one or both eyes. Participating EPs completed a one hour didactic lecture and were expected to demonstrate appropriate performance of one practice scan before enrolling patients. After standard ED assessment, patients underwent an ocular POCUS scan targeted to detect RD. EPs recorded the presence or absence of RD on the data collection instrument based on their POCUS scan. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CI) using the retina specialist’s determination of the final diagnosis as the criterion standard. Results: A total of 30 EPs, consisting of 21 staff physicians and 9 residents, participated in this study. These EPs performed a total of 128 POCUS scans. Of these scans, 13 were excluded. Of the remaining 115 enrolled patients, median age was 60 years, and 64% were female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD was 75% (95% CI 48% to 93%) and 94% (95% CI 87% to 98%), respectively. The positive likelihood ratio was 12.4 (95% CI 5.4 to 28.3), and negative likelihood ratio was 0.27 (95% CI 0.11 to 0.62). Conclusion: In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.
P048: Profiling the burdens of working nights. Traditional 8-hour nights vs staggered 6-hour casino shifts in an academic emergency department
Authors: Dong A.X. , Columbus M. , Arntfield R. , Thompson D. , Peddle M.
Published: May 2017

Introduction: Emergency physicians (EP) often work at undesirable hours. In response to deleterious effects on quality of life for EPs, traditional 2300-0700 night shifts have been replaced at some centres with staggered 6-hour casino shifts (22:00-04:00 and 04:00-10:00). Though purported to allow for better sleep and recovery patterns, no evidence exists to support the benefits on sleep or quality of life that is used to justify a casino shift model. Using a before and after survey model, this study examines the impact of overhauling night work from a traditional 8-hour shift to casino shifts on the quality of life and job satisfaction of EPs working in an academic emergency department (ED). Methods: In 2010, an initial online, 37-item survey, was sent to all EPs working in the ED, just prior to the transition to casino shifts. 6 years following the transition, a slightly modified 37-item survey was again distributed to all current EPs working at that same centre. Participants rated their level of agreement on a 7-point Likert scale regarding questions related to night work. Results from the two surveys were compared. Results: 43 2010- and 47 2016-surveys were completed. In 2016, recovery to baseline function after a single early shift (22:00-04:00) was most common after 1 day at 52.4%, and after multiple early shifts was ≥2 days at 66.7%. Recovery after a single late shift (04:00-10:00) was most common at 1 day at 54.8%, and after multiple late shifts was ≥2 days at 59.5%. This was in contrast to 2010, when 55.8% recovered from a single traditional night shift after 1 day, and 95.3% required ≥2 days to recover from multiple traditional night shifts. In relation to casino shifts, 40.5% of respondents stated that night shifts are the greatest drawback of their job, compared to 79.1% previously. A minority of respondents felt that teaching (36.5%), diagnostic test interpretation (23.2%), and quality of handover (33.5%) were inferior on early and late night shifts compared to other shifts (74.4%, 58.1%, and 60.5% for traditional night shifts respectively).95.0% of respondents preferred casino over traditional night shifts. Conclusion: There were self-reported improvements in all domains following the implementation of casino shifts.
P050: A prospective cohort study to evaluate discharge care for patients with atrial fibrillation and flutter (AF/AFL)
Authors: Duke P. , Patrick S. , Lobay K. , Haager M. , Deane B. , Couperthwaite S. , Villa-Roel C. , Rowe B.H.
Published: May 2017

Introduction: Atrial fibrillation and flutter (AF/AFL) are the most common arrhythmias encountered in the emergency department (ED); however, little information exists regarding the preventive management of patients with AF/AFL by emergency physicians (EPs). This study explored whether patients with AF/AFL received the recommended thrombo-embolic (TE) prophylaxis at discharge from the ED; patients’ TE risks, bleeding risks, and TE prophylaxis upon discharge from the ED were examined following assessment for symptomatic acute AF/AFL. Methods: Patients ≥18 years of age identified by the EP as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three urban Canadian EDs. Using standardized patient enrollment forms, trained research assistants collected data on the patient’s demographics, TE risk (using the CHADS2 and CHA2DS2-VASc score), bleeding risk (using the HAS-BLED score), and management both in the ED and at discharge. Treating physicians were surveyed on their use of risk scores when making TE prophylaxis decisions as well as their estimate of the patient’s stroke and bleeding risk. Descriptive analyses were performed. Results: From a total of 196 patients, 62% were male and the mean age was 63 years (standard deviation [SD] ±14). Most patients had previous history of AF/AFL (71%); hypertension was documented in 40% of them and ≤10% had other risk factors (e.g., congestive heart failure, vascular disease, diabetes, previous stroke, transient ischemic attack). Based on the CHADS2 score and previous management, there was opportunity for new or revised antiplatelet/anticoagulant treatment by EPs in 19% of the patients. Consultations were requested in 28% of the patients, and the majority (89%) were discharged with anticoagulant or antiplatelet agents. EPs expressed concerns that an increased risk of falls, lack of access to facilities for INR monitoring, and significant cognitive impairment would affect their willingness to prescribe anticoagulation. Conclusion: Most patients in the ED with acute AF/AFL are receiving the recommended TE prophylaxis; however, given the significant morbidity and mortality associated with AF/AFL, improved short-term prescribing practices for anticoagulants would benefit 1 in 5 ED patients. More research on barriers to EPs prescribing anticoagulants is required to improve clinician comfort in treating this high-risk population.
P052: The importance of structured ambulance radio patches during termination of resuscitation calls
Authors: Eby D. , Woods J.
Published: May 2017

Introduction: Pre-hospital telecommunication (patches) requires a special type of conversation. Receiving and processing correct information is critical when making clinical decisions, such as a termination of resuscitation (ToR). In a study of radio patches, a common patch structure emerged from the data analysis. Use of this standard structure resulted in shorter and less confusing patches. We sought to understand patch structure to be able to target interventions to improve the quality and efficiency of communication needed for critical clinical decisions. Methods: We undertook a retrospective analysis of all ToR patches between physicians and paramedics from 4 paramedic services, recorded by the Ambulance Dispatch Centre between Jan 01-Dec 31, 2014. Four services used Primary Care Paramedics and 1 service also used Advanced Care Paramedics. MP3 patch recording files were anonymized, transcribed, and read multiple times by the authors. Transcripts were coded and analyzed using mixed methods-quantitative descriptive statistics and qualitative thematic framework analysis. Results: The data set was 127 ToR patches-466 pages of transcripts. 116 patches (91.3%) had a standard structure (SS): participant introduction, clinical data presentation, clarification of data, making the decision, exchange of administrative information, and sign off. Paramedics used a mean of 81 words (95CI 74,88) to present the ‘clinical data’. Enough data was presented to meet ToR rule criteria in 52 cases (44.8%). Before making a decision to terminate resuscitation, physicians sought clarification in 100 cases (78.7%). After making the ToR decision, some physicians needed to justify their decision by seeking more data in 17 cases (13.4%). Exchange of non-clinical information (numbers, times, name spellings) took a mean of 200 words (95CI 172,228) and averaged 84 seconds or 35% of the average patch time. SS patches used a mean of 558 words, and lasted 234 sec (95CI 215,252). Non-SS patches used a mean of 654 words and lasted 286 sec (95CI 240,332). Conclusion: The most common patch structure consisted of participant introduction, data presentation, clarification of data, making the clinical decision, exchange of administrative information, and a sign off. Deviation from this SS resulted in longer patches. When a non-SS patch structure was used, the patching paramedic was tied up 25% longer and unavailable to provide patient care.
P054: Do biomarkers need clinical attention among pre-frail injured seniors seen in the ED
Authors: Blouin M. , Sirois M. , Aubertin-Leheudre M. , Griffith L.E. , Nadeau L. , Daoust R. , Lee J.S. , Émond M.
Published: May 2017

Introduction: Frailty is associated with functional decline and physiological impairments in seniors with minor injuries. Serum biomarkers have also been suggested as potential markers of these impairments in clinical studies. However, no study has addressed the usefulness of serum biomarkers among pre-frail seniors consulting emergency departments (ED) in order to detect these impairments.Objectives: The purpose of the present study was to explore the association between several serum biomarkers and the frailty status of seniors seen in ED for a minor injury who are at risk of functional decline and 2) assist professionals in clinical decisions while identifying frail seniors in whom interventions should be started in order to prevent potential functional decline. Methods: This cross-sectional study includes 190 seniors retrieved from the larger CETI cohort and discharged home from 4 EDs after treatment of minor injuries. Their frailty status was measured by the Canadian Study of Health & Aging-Clinical Frailty Scale (CSHA-CFS). Then, patients were classified as “Robust” (CHSA-CFS levels 1 and 2) vs. “Pre-frail/Frail” (CHSA-CFS levels ≥3). Biomarkers (Albumin, Creatinine, C-reactive protein (CRP), Vitamin D, Ferritin, Glucose and Insulin-Growth Factor (IGF-1)) were obtained from blood samples. “Normal” vs. “Impaired” (low and/or high) clinical threshold values were used for statistical analyses. Results: The proportion of patients with clinically high creatinine levels (>105 µmol/L for male and >85 µmol/L for female) was higher in Pre-frails/Frails when compared to Robusts (P-value=0.01). Also, regarding IGF-1, we observed that the proportion of patients with lower IGF-1 levels (<50 µg/L) was higher in patients showing Pre-frail/Frail status (P-value=0.01). Finally, a significant correlation was found between frailty status and blood glucose (r=0.22; P-value=0.02) whereas a tendency was noted for CRP level (r=0.14; P-value=0.1). Conclusion: When compared to Robust seniors, Pre-frail/Frail individuals presenting to EDs tend to have physiological dysregulations that may help detect pre-frail status in community-dwellers. Larger prospective studies are needed to specify the usefulness and clinical implications of frailty biomarkers in the continuum of acute elder care.
P055: EMS boot camp: a real-world, real-time educational experience for emergency medicine residents
Authors: Farrell C. , Teed S. , Costain N. , Austin M.A. , Willmore A. , Reed A. , Maloney J. , Dionne R.
Published: May 2017

Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.
P057: Diagnosis for mild traumatic brain injury in three Canadian emergency departments: missed opportunities
Authors: Gaudet L. , Eliyahu L. , Lowes J. , Beach J. , Mrazik M. , Cummings G. , Latoszek K. , Carroll L. , Holroyd B.R. , Rowe B.H.
Published: May 2017

Introduction: Patients with mild traumatic brain injury (mTBI) often present to the emergency department (ED). Incorrect diagnosis may delay appropriate treatment and recommendations for these patients, prolonging recovery. Notable proportions of missed mTBI diagnosis have been documented in children and athletes, while diagnosis of mTBI has not been examined in the general adult population. Methods: A prospective cohort study was conducted in one academic (site 1) and two non-academic (sites 2 and 3) EDs in Edmonton, Canada. On-site research assistants enrolled adult (>17 years) patients presenting within 72 hours of the injury event with clinical signs of mTBI and Glasgow comma scale score ≥13. Patient demographics, injury characteristics, and ED flow information were collected by chart review. Physician-administered questionnaires and patient interviews documented the recommendations given by emergency physicians at discharge. Bi-variable comparisons are reported using Pearson’s chi-square tests, Student’s t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, 130/250 enrolled patients were female, and the median age was 35. Proportions of successfully diagnosed mTBI varied significantly across study sites (Site 1: 89%; Site 2: 73%, Site 3: 53%; p>0.001). Patients without a diagnosis were less likely to receive a recommendation to follow-up with their family physician (OR=0.08; 95% CI: 0.03, 0.21) or advice about return to work (OR=0.17; 95% CI: 0.08, 0.04) or physical activity (OR=0.08; 95% CI: 0.04, 0.17). Patients with missed diagnoses had longer ED stays (median=5.0 hours; IQR: 3.8, 7.0) compared with diagnosed mTBI patients (median=3.9 hours; IQR: 3.0, 5.3). In the adjusted model, patients presenting to non-academic centers had reduced likelihood of mTBI diagnosis (Site 2: OR=0.21; 95% CI: 0.08, 0.58; Site 3: OR=0.07; 95% CI: 0.02, 0.24). Conclusion: The diagnostic accuracy of physicians assessing patients presenting with symptoms of mTBIs to these three EDs is suboptimal. The rates of missed diagnosis vary among EDs and were associated with length of ED stay. Closer examination of institutional factors, including diagnosis processes and personnel factors such as physician training, is needed to identify effective strategies to heighten the awareness of mTBI presentations.
P058: Morbid obesity association with return of spontaneous circulation from sudden cardiac arrest treated in a large, urban EMS system in the United States
Authors: Goodloe J.M. , Vinson L.D. , Cox M.L. , Burns B.D.
Published: May 2017

Introduction: Patient co-morbidities contribute to survivability from out-of-hospital sudden cardiac arrest. Many studies have been conducted regarding contributing factors to sudden cardiac arrest survival, though very few studies have been published detailing specific analysis of morbid obesity association with return of spontaneous circulation (ROSC) in adults treated by paramedics. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Due to an increasing prevalence of morbid obesity in the United States adult population, a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was initiated in June 2016. As exact body weight is logistically difficult to obtain in the EMS care environment, a paramedic-estimated weight at the time of resuscitation to be 100 kg or greater was deemed representative of “morbid obesity” for this analysis. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT, Physio-Control Corporation, Redmond, WA). ROSC was determined from both paramedic and hospital clinician EMRs reviewed by a paramedic researcher. Results: During the 5 month study period, paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 49/90 (54.4%) with weight <100 kg as estimated by paramedics at the time of resuscitative care achieved at least transient ROSC. Only 17/43 (39.5%) with estimated weight ≥100 kg achieved any ROSC, despite paramedics authorized to perform defibrillations at higher joule energy settings for such weight. The OR for ROSC if <100 kg estimated weight is 1.83 (95% CI 0.87-3.83), though given limited sample size p=0.11. Conclusion: While survival from out-of-hospital sudden cardiac arrest in adults is multi-factorial, the presence of morbid obesity, defined as estimated weight ≥100 kg, trends towards less ROSC. Continued community health efforts to decrease the prevalence of morbid obesity in the adult population may confer improved ability to survive out-of-hospital sudden cardiac arrest.
P061: Preventable adverse drug events in Canadian emergency departments
Authors: Hohl C.M. , Woo S. , Cragg A. , Ackerley C.R. , Wickham M.E. , Villanyi D. , Scheuermeyer F.X.
Published: May 2017

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.
P062: SOS: Summer of Smoke--a mixed-methods, community-based study investigating the health effects of a prolonged, severe wildfire season on a subarctic population
Authors: Howard C. , Rose C. , Dodd W. , Scott P. , Cunsulo-Willox A. , Orbinski J.
Published: May 2017

Introduction: Between June 15 and Aug 31st 2014, Canada’s Northwest Territories (pop 44,000: Stats Can), a subarctic region which is over 2°C warmer than it was in the 1950’s, experienced an unprecedented number of forest fires, with 385 fires and approximately 3.4 million hectares of forest affected. This resulted in one of Canada’s most severe and prolonged urban smoke exposures for the capital city of Yellowknife and surrounding Aboriginal communities. Our objective was to obtain a big-picture sense of the health impact of the Summer of Smoke on the population of these communities through a mixture of quantitative and qualitative analysis. Methods: We analyzed PM2.5 levels, salbutamol dispensations, clinic and hospital cardiorespiratory variables, and in-depth video interviews with community members from Yellowknife, N’Dilo, Dettah and Kakisa. Results: 49% of days June15-Aug31 in 2014 had a PM2.5 over 30 mcg/m3, as compared to 3% in 2012 and 9% in 2013 and 2015. Max daily PM 2.5 in 2014 was 320.4 mcg/m3. There was a 22% increase in outpatient salbutamol dispensations in 2014 compared to the average of 2012, 2013 and 2015. More cough, pneumonia and asthma were seen in clinics compared to 2012-2015 (P<0.001). There was a 42% increase in respiratory ER visits in 2014 compared to 2012-13, but no change in cardiac variables. The respiratory effect was most pronounced in children 0-4 (114% increase in ER visits). Qualitative analysis demonstrates themes of fear, isolation, lack of physical activity, alteration of traditional summertime activities for both aboriginal and non-aboriginal subjects, elements of resilience and expectation for future smoky summers in the context of a changing climate. Conclusion: Prolonged wildfire seasons have a profound effect on overall wellbeing. Responses to help minimize mental and physical impacts such as the creation of clean-air community shelters, recreation programming, initiatives to support community cohesion, and “go outside when it is not smoky” messaging require further study.
P066: Outcomes of non-operative versus operative management in pediatric acute uncomplicated appendicitis
Authors: Janjua W. , Janjua A. , Loubani E. , Merritt N. , Van Aarsen K.
Published: May 2017

Introduction: The purpose of this study was to look at outcomes of pediatric patients with early, acute appendicitis who were treated with non-operative management (NOM) with antibiotics. Primary outcomes were subsequent appendectomy or Emergency Department (ED) visits. Methods: The method used for this study was a retrospective chart review of children under the age of 18, looking at outcomes of those who received non-operative management (NOM) for early acute appendicitis between April 2014-April 2015. The inclusion criteria included: (a) Age 0-17, (b) US or CT suggested acute uncomplicated appendicitis (c) Final diagnosis of appendicitis during April 2014-2015. Outcomes that were investigated were repeat ED visits and need for subsequent appendectomy. Results: Data extracted from the EMR found 209 charts with an ED diagnosis of appendicitis. Two charts (.9%) were excluded as they were duplicates. Sixty-seven patients (32%) were excluded after appendicitis was ruled out. One hundred and forty patients (67%) had a final diagnosis of appendicitis, 124 patients (88.6%) were taken directly to the operating room for appendectomy, 16 patients (11.4%) were treated with antibiotics instead of operative management. Three patients who received non-operative management had complex appendicitis, 13 had acute uncomplicated appendicitis. Six patients out of 13 (46%) were successfully treated with antibiotics with no repeat visits to the ED or Pediatric Surgery for appendectomy, 7 patients (54%) required appendectomy after initial treatment with antibiotics. Two patients who underwent appendectomy after initial NOM had no evidence of clinical appendicitis, one patient was taken to the OR based on parent preference and one patient had an episode of abdominal pain that prompted an interval appendectomy four weeks post the episode of abdominal pain. Conclusion: Treatment of acute uncomplicated appendicitis with NOM remains a management option in the pediatric population. Further studies and long term follow up are required to better identify appropriate patients for non-operative management versus operative management.
P067: Factors associated with prolonged length of stay of admitted patients in a tertiary care emergency department
Authors: Johns K. , Smith S. , Karreman E. , Kastelic A.
Published: May 2017

Introduction: Extended length of stay (LOS) in emergency departments (EDs) and overcrowding are a problems for the Canadian healthcare system, which can lead to the creation of a healthcare access block, a reduced health outcome for acute care patients, and decreased satisfaction with the health care system. The goal of this study is to identify and assess specific factors that predict length of stay in EDs for those patients who fall in the highest LOS category. Methods: A total of 130 patient charts from EDs in Regina were reviewed. Charts included in this study were from the 90th-100th percentile of time-users, who were registered during February 2016, and were admitted to hospital from the ED. Patient demographic data and ED visit data were collected. T-tests and multiple regression analyses were conducted to identify any significant predictors of our outcome variable, LOS. Results: None of the demographic variables showed a significant relationship with LOS (age: p=.36; sex: p=.92, CTAS: p=.48), nor did most of the included ED visit data such as door to doctor time (p=.34) and time for imaging studies (X-ray: p=.56; ultrasound: p=.50; CT p=.45). However, the time between the request for consult until the decision to admit did show a significant relationship with LOS (p<.01).Potential confounding variables analyzed were social work consult requests (p=.14), number of emergency visits on day of registration (p=.62), and hour of registration (00-12 or 12-24-p<.01). After adjustment for time of registration, using hierarchical multiple regression, time from consult request to admit decision maintained a significant predictor (p<.01) of LOS. Conclusion: After adjusting for the influence of confounding factors, “consult request to admit decision” was by far the strongest predictor of LOS of all included variables in our study. The results of this study were limited to some extent by inconsistencies in the documentation of some of the analyzed metrics. Establishing standardized documentation could reduce this issue in future studies of this nature. Future areas of interest include establishing a standard reference for our variables, a further analysis into why consult requests are a major predictor, and how to alleviate this in the future.
P078: Derivation and validation of a non return to work predictive model three months after a mild traumatic brain injury
Authors: Le Sage N. , Chauny J. , Émond M. , Moore L. , Archambault P.M. , De Guise É. , Ouellet M. , Tardif P. , Mercier E.
Published: May 2017

Introduction: Mild traumatic brain injury (mTBI) is a common problem and until now, ED physicians don’t have any tool to predict when the patient will return to work. The purpose of this study is to develop and validate a clinical decision rule to identify the ED patients who are at risk of non-return to work or to school three months after a mTBI. Methods: Patients were recruiting in five Level I and II Trauma Centers ED in the province of Québec. All patients were referred for a systematic telephone follow-up after three months. Information about their return to work/school, partial or complete, was collected. Log binomial regression was used to develop a predictive model and the validation of this model was performed on a different prospective cohort. Results: 13,7% of the patients did not return to work/school at three months. The final model was derived from a prospective cohort of 398 patients and included three risk factors: motor vehicle accident (2 points), loss of consciousness (1 point) and headache during the emergency department assessment (1 point). With a one-point threshold, this model has a sensitivity of 97% and a negative predictive value (NPV) of 98%. However, the specificity is only 23% and the positive predictive value (PPV) is 17%. The area under the curve is 0.786. Validation of the model was performed with a new prospective cohort of 517 patients, and demonstrated a sensitivity of 86% and a NPV of 91%. Conclusion: Although this model is not very specific, its high sensitivity and NPV indicate to the clinician that mTBI patients who don’t have any of the three criteria are at low risk of prolonged work stoppage after their trauma.
P080: A descriptive analysis of prehospital midazolam as a chemical restraint in combative patients
Authors: Davis M. , Leggatt L. , Bradford P. , Morassutti P. , Van Aarsen K. , Leschyna M.W.
Published: May 2017

Introduction: Paramedics are often required to manage violent or combative patients. In order to do so safely, chemical sedation may be required. There are a number of pharmacologic agents which may be used. However, there is a paucity of evidence as to the optimal agent. Objective: To provide a descriptive analysis of a single base hospital’s experience with combative patients and to determine the efficacy and any adverse events (AEs) in the prehospital setting, associated with midazolam use in these patients. Methods: A retrospective chart review of ambulance calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were filtered and manually examined. Patients were excluded if they were 17 or younger. A priori data points were abstracted by trained research personnel from the ambulance call record. Results: Of approximately 350,000 calls over the study period, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam for sedation. Multiple doses were required in 33.3% of patients. Depending on route of administration, the average total dose administered was 6.27 mg (SD 3.98 mg) intramuscular, 10.7 mg (SD 4.00 mg) intranasal and 4.95 mg (SD 3.81 mg) intravenous. Midazolam was documented as effective in treating the combativeness in 133 (71.6%), ineffective in 28 (15.1%), and not documented in 25 (13.4%) calls. AEs post midazolam administration, defined as hypotension, bradypnea, bradycardia, or need for airway intervention, were encountered in 3 (1.61%) calls (respiratory rate of 8, hypotension of 88/59 that responded to intravenous fluid and asymptomatic bradycardia of 59). There was a trend of increasing number of combative patients each year over the study period, with a significant difference in the number of combative calls requiring midazolam administration between 2012 and 2015 (50.0% vs 72.8%, p=0.007). Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with minimal AEs. However, midazolam was ineffective in 15.1% and a third of all patients required multiple doses, prolonging the combative period and compromising paramedic and patient safety. Further research is warranted for this cohort’s emergency department (ED) sedation needs and any associated AEs within 1 hour of ED arrival.
P082: Current state of POCUS usage in canadian emergency departments
Authors: Leschyna M.W. , Hatam E.M. , Britton S.R. , Van Aarsen K. , Detombe S.A. , Sedran R.
Published: May 2017

Introduction: Point of care ultrasound (POCUS) has many applications in Emergency Medicine which are proven to improve patient outcomes. Training programs and guidelines for its use are available but its utilization metrics across Canadian Emergency Departments are unknown. This study aims to provide a comprehensive national assessment of POCUS usage, with a key component comparing training with patterns of use. Methods: A survey was distributed via email to all staff adult emergency physician members of the Canadian Association of Emergency Physicians (CAEP). The survey included questions related to training, attitudes towards POCUS, POCUS utilization, and barriers to POCUS use. Standard descriptive statistics were calculated, and differences in mean POCUS usage between groups were measured using a one-way analysis of variance (ANOVA). Results: The survey received 189 responses from emergency physicians from across Canada, 81% of which viewed POCUS as “useful and essential”. Respondents indicated that on average, POCUS was used during 71% (SD 29%) of shifts and on 23% (SD 17%) of patients. POCUS was most commonly used for basic applications, including thoracoabdominal trauma (FAST), cardiac assessment in arrest (trans-abdominal), and assessing for pericardial effusion. The most commonly cited barrier to wider POCUS adoption was a lack of training, with 41% of respondents identifying this as an issue. Correspondingly, formal POCUS training and certification were associated with significantly higher POCUS usage: usage rates ranged from 11.5% (SD 10.5%) of patients for those with formal training but no certification to 39.5% (SD 16.4%) of patients for those with a POCUS fellowship (p <0.001). Conclusion: The presented results from this survey provide an initial overview of the current state of POCUS usage in Canadian Emergency Departments. In summary, a higher level of training was associated with higher POCUS usage, and over a third of the respondents cited lack of training as a barrier to adoption; this suggests that efforts to facilitate POCUS utilization should focus on improving access to formal training and certification. Future work will involve further evaluation of additional barriers preventing POCUS usage in the ED, with the goal of providing information that will encourage changes that support widespread POCUS adoption.
P083: IV fluid resuscitation of sepsis patients in London, ON: a retrospective chart review
Authors: Leung A. , Aguanno A. , Van Aarsen K.
Published: May 2017

Introduction: The Surviving Sepsis Campaign (SSC) suggests that hypovolemic patients, in the setting of hypoperfusion, be administered 30 mL/kg crystalloid fluid within the first 3 hours of presentation to hospital. More recent evidence suggests that fluid resuscitation within 30 min of sepsis identification is associated with reduced mortality, hospital length of stay and ICU days. This study describes Emergency Department (ED) fluid resuscitation of patients with septic shock and/or sepsis-related in-hospital mortality, prior to implementation of a sepsis medical directive. Methods: Retrospective chart review of adult patients (18+ years), presenting to two tertiary care EDs between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis. Data were abstracted from electronic health records. Patients with septic shock, or who expired in the ED/hospital, were selected for manual chart review of clinical variables including: time, type and volume of ED IV fluid administration. Results: 13,506 patient encounters met inclusion criteria. In-hospital mortality rates were 2% (sepsis), 11.5% (severe sepsis), and 24.1% (septic shock). Of patients hypotensive at triage, fluids were administered to 33/50 (66.00%) septic shock patients, and 22/43 (51.16 %) patients who eventually expired. For all septic shock and expired patients (943), median time to IV fluid initiation was 60.50 minutes [29.75 to 101.25] for septic shock and 77.00 minutes [36.00 to 127.00] for expired patients. Median volume of fluid administered was 1.50L [1.0 to 2.00] for septic shock and 1.00L [1.00 to 2.00] for expired patients. Of septic shock and expired patients, IV fluid administration and body weight data was available for 148 encounters (15.6%). Within this group, 19 (12.8%) received no IV fluid. 90 (60.8%) received 0.1-75% of their recommended IV fluid volume. 25 (16.9%) received 75.1-125%, and 14 (9.4%) received >125.1% of their recommended fluid volume. Conclusion: In this study, severe forms of sepsis were often treated with <30 mL/kg crystalloid fluid. Fluids were administered outside of the recommended 30 min, but within the 3 h, time windows. In-hospital mortality was consistent with published data. Future research will examine a broader data set for IV fluid resuscitation in sepsis, and will measure the impact of a fluid resuscitation in sepsis medical directive.