bluuebunny/crossref_metadata_2025 huggingface dataset:
Human Responses to 5 Heated Hypothermia Wrap Systems in a Cold Environment
Authors: Dutta Ramesh , Kulkarni Kartik , Steinman Alan M. , Gardiner Phillip F. , McDonald Gerren K. , Giesbrecht Gordon G.
Published: May 2019

Introduction

We compared the effectiveness of 5 heated hypothermia wrap systems.

Methods

Physiologic and subjective responses were determined in 5 normothermic subjects (1 female) for 5 heated hypothermia wraps (with vapor barrier and chemical heat sources) during 60 min of exposure to a temperature of −22°C. The 5 systems were 1) user-assembled; 2) Doctor Down Rescue Wrap; 3) hypothermia prevention and management kit (HPMK); 4) MARSARS Hypothermia Stabilizer Bag; and 5) Wiggy's Victims Casualty Hypothermia Bag. Core and skin temperature, metabolic heat production, skin heat loss, and body net heat gain were determined. Subjective responses were also evaluated for whole body cold discomfort, overall shivering rating, overall temperature rating, and preferential ranking.

Results

The Doctor Down and user-assembled systems were generally more effective, with higher skin temperatures and lower metabolic heat production; they allowed less heat loss, resulting in higher net heat gain ( P<0.05). HPMK had the lowest skin temperature and highest shivering heat production and scored worse than the other 4 systems for the “whole body cold discomfort” and “overall temperature” ratings ( P<0.05).

Conclusions

The user-assembled and Doctor Down systems were most effective, and subjects were coldest with the HPMK system. However, it is likely that any of the tested systems would be viable options for wilderness responders, and the choice would depend on considerations of cost; volume, as it relates to available space; and weight, as it relates to ability to carry or transport the system to the patient.
Preventing software from opening doors to the network
Authors: Herbert Sean
Published: May 2019

Without doubt, at some point the device on which you are reading these words has prompted you to perform a software update. A regular occurrence and an occasional nuisance, these updates might not always bring exciting and evident UI improvements, but always deliver critical under-the-hood security fixes to patch holes in the software by addressing and replacing faulty programming.
LO63: Humanoid robot-based distraction to reduce pain and distress during venipuncture in the pediatric emergency department: A randomized controlled trial
Authors: Ali S. , Manaloor R. , Ma K. , Sivakumar M. , Vandermeer B. , Beran T. , Scott S. , Graham T. , Curtis S. , Jou H. , Beirnes N. , Hartling L.
Published: May 2019

Introduction: Intravenous insertion (IVI) is identified by children as extremely painful and the resultant distress can have lasting negative consequences. There is an urgent need to effectively manage such procedures. Our primary objective was to compare the pain and distress of IVI with the addition of humanoid robot-based distraction to standard care, versus standard care alone. Methods: This two-armed randomized controlled trial (RCT) was conducted from April 2017 to May 2018 at the Stollery Children's Hospital emergency department (ED). Children aged 6 to 11 years who required IVI were included. Exclusion criteria included hearing or visual impairments, neurocognitive delays, sensory impairment to pain, previous enrolment, and discretion of the ED clinical staff. Primary outcomes were measured using the Observational Scale of Behavioural Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). A total of 426 pediatric patients were screened and 340 were excluded. Results: We recruited 86 children, of which 55% (47/86) were male; 9% (7/82) were premature at birth; 82% (67/82) had a previous ED visit; 30% (25/82) required previous hospitalization; 78% (64/82) had previous IV placement and 96% (78/81) received topical anesthesia. The mean total OSBD-R score was 1.49 ± 2.36 (standard care) compared to 0.78 ± 1.32 (robot group) (p = 0.047). The median FPS-R during the IV procedure was 4 (IQR 2,6) in the standard care group alone, compared to 2 (IQR 0,4) with the addition of humanoid robot-based distraction (p = 0.10). Change in parental state anxiety pre-procedure versus post-procedure was not significantly different between groups (p = 0.49). Parental satisfaction with the IV start was 93% (39/42) in the robot arm compared to 74% (29/39) in the standard care arm (p = 0.03). Parents were also more satisfied with management of their child's pain in the robot group (95% very satisfied) compared with standard care (72% very satisfied) (p = 0.002). Conclusion: A statistically significant reduction in distress was observed with the addition of robot-based distraction to standard care. Humanoid robot-based distraction therapy reduces distress and to a lesser extent, pain, in children undergoing IVI in the ED. Further trials are required to confirm utility in other age groups and settings.
LO64: The HEART score in predicting major adverse cardiac events in patients presenting to the emergency department with possible acute coronary syndrome: a systematic review and meta-analysis
Authors: Byrne C. , Toarta C. , Backus B. , Holt T.
Published: May 2019

Introduction: Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. The objective of this review was to investigate the ability of the HEART score to predict major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS. Methods: Eleven databases and other sources identified 468 potentially relevant studies. Sixty-seven studies underwent full text review with 25 studies meeting eligibility criteria. Main outcome measures were pooled prevalence, risk ratio (RR), and absolute risk reduction (ARR) for MACE within six weeks of ED evaluation, comparing HEART score 0–3 versus 4–10. Model discrimination (sensitivity, specificity, concordance statistic) and calibration (observed to expected events ratio) were also evaluated. Results: Data from 25 studies including 41,397 patients were combined in the meta-analysis. In total, 4815 patients (11.6%) developed MACE. Among 18,866 patients with HEART score 0–3, 396 (2.1%) developed MACE (RR 0.08; ARR 0.20). Outcome measures were consistent across planned subgroup and sensitivity analyses. Among studies with secondary outcome data for patients with HEART score 0–3, 5 of 6461 (0.1%) died and 75 of 7556 (1.0%) had a myocardial infarction. Conclusion: The HEART score provides a reliable quantitative risk assessment of MACE in ED patients with possible ACS. Emergency clinicians should consider using the HEART score to facilitate risk communication and shared decision making with patients and other care providers.
LO67: Association between hypotension and mortality in critically ill patients with severe traumatic brain injury: experience at a single Canadian trauma center
Authors: Green R. , Erdogan M. , Kureshi N. , Clarke D.
Published: May 2019

Introduction: Hypotension is known to be associated with increased mortality in severe traumatic brain injury (TBI) patients. Systolic blood pressure (SBP) of <90 mmHg is the threshold for hypotension in consensus TBI treatment guidelines; however, evidence suggests hypotension should be defined at higher levels for these patients. Our objective was to determine the influence of hypotension on mortality in TBI patients requiring ICU admission using different thresholds of SBP on arrival at the emergency department (ED). Methods: Retrospective cohort study of patients with severe TBI (Abbreviated Injury Scale Head score ≥3) admitted to ICU at the QEII Health Sciences Centre (Halifax, Canada) between 2002 and 2013. Patients were grouped by SBP on ED arrival ( <90 mmHg, <100 mmHg, <110 mmHg). We performed multiple logistic regression analysis with mortality as the dependent variable. Models were adjusted for confounders including age, gender, Injury Severity Score (ISS), injury mechanism, and trauma team activation (TTA). Results: A total of 1233 patients sustained a severe TBI and were admitted to the ICU during the study period. The mean age was 43.4 ± 23.9 years and most patients were male (919/1233; 74.5%). The most common mechanism of injury was motor vehicle collision (491/1233; 41.2%) followed by falls (427/1233; 35.8%). Mean length of stay in the ICU was 6.1 ± 6.4 days, and the overall mortality rate was 22.7%. SBP on arrival was available for 1182 patients. The <90 mmHg group had 4.6% (54/1182) of these patients; mean ISS was 20.6 ± 7.8 and mortality was 40.7% (22/54). The <100 mmHg had 9.3% (110/1182) of patients; mean ISS was 19.3 ± 7.9 and mortality was 34.5% (38/110). The <110 mmHg group had 16.8% (198/1182) of patients; mean ISS was 17.9 ± 8.0 and mortality was 28.8% (57/198). After adjusting for confounders, the association between hypotension and mortality was 2.22 (95% CI 1.19-4.16) using a <90 mmHg cutoff, 1.79 (95% CI 1.12-2.86) using a <100 mmHg cutoff, and 1.50 (95% CI 1.02-2.21) using a <110 mmHg cutoff. Conclusion: While we found that TBI patients with a SBP <90 mmHg were over 2 times more likely to die, patients with an SBP <110 mmHg on ED arrival were still 1.5 times more likely to die from their injuries compared to patients without hypotension. These results suggest that establishing a higher threshold for clinically meaningful hypotension in TBI patients is warranted.
LO69: A retrospective cohort study on the impact of point-of-care ultrasound on radiologic imaging in patients presenting to the emergency department with suspected uncomplicated renal colic
Authors: Alain J. , Huard R. , Mokhtari A. , Parent M. , Simonyan D. , Berthelot S.
Published: May 2019

Introduction: The number of CT scans prescribed in the Emergency department (ED) for suspected renal colic has increased over recent years without an associated improvement in patient-centred outcomes. We assessed whether Point-of-Care Ultrasound (PoCUS) decreases the use of formal radiologic imaging. Methods: We completed a retrospective cohort study on consecutive patients 18 years of age and older presenting to the ED with suspected uncomplicated renal colic in a tertiary care centre in Québec in 2016. Exclusion criteria included: previous urologic intervention, solitary kidney, dialysis, fever, pyuria, acute kidney injury, pregnancy, suspicion of a serious alternative diagnosis or persistent symptoms despite analgesia. We compared the proportion (95%CI) of formal radiologic imaging performed (Ultrasound or CT) in patients who had PoCUS in the ED vs. those who did not. Two-tailed Fisher exact test (α = 0.05) and odds ratios (95%CI) calculated from multivariate logistic regression models adjusted for age, gender, Charlson Index and previous renal colic were used to compare the two groups. The reliability of data collection was evaluated with a kappa score (95%CI). Results: 169 patients with uncomplicated renal colic were included. There was no difference between the groups in terms of age, gender, Charlson Index, or previous renal colic. The PoCUS level of training and the doctor's education level was significantly higher in the PoCUS group. There was a non-significant trend towards less formal imaging in patients of the PoCUS group 65/88 (73.9% [63.4-82.7%]) vs. the non-PoCUS group 69/81 (85.2% [75.6-92.1%]), p = 0.087. After adjustment for confounders, the patients not evaluated with PoCUS were more likely to have formal imaging with a significant odds ratio of 2.41 [1.05-5.56]). Among patients who underwent a CT, incidentalomas were found in 16.5% and only 2.0% demonstrated significant findings leading to changes in ED management, such as an alternative diagnosis, need for admission, or an urgent urological intervention. Inter-observer agreement was excellent between assessers with a kappa score of 0.88 [0.66-1.00]. Conclusion: ED patients with uncomplicated renal colic who are investigated with PoCUS tend to have fewer formal imaging test. When CT scans were performed, incidentalomas were found in 16.5% and ED management changed only 2.0% of the time. PoCUS appears to be a useful tool for decreasing CT utilisation in this low-risk ED population.
LO70: Functional & cognitive decline in older delirious adults after an emergency department visit
Authors: Giroux M. , Sirois M. , Nadeau A. , Boucher V. , Carmichael P. , Voyer P. , Pelletier M. , Gouin É. , Daoust R. , Berthelot S. , Lamontagne M. , Morin M. , Lemire S. , Émond M.
Published: May 2019

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.
LO78: A qualitative evaluation of a mandatory provincial program auditing emergency department return visits
Authors: Jalali H. , Ostrow O. , Dainty K. , Seaton B. , Ovens H. , Borgundvaag B. , McLeod S. , Chartier L.
Published: May 2019

Introduction: The Ontario emergency department (ED) Return Visit Quality Program (RVQP) launched in 2016 and aims to promote continuous quality improvement (QI) in the province's largest EDs. The program mandates routine audits of cases involving patients who had ED return visits within 72hrs that led to admission to hospital, in order to identify quality issues that can be tackled through QI initiatives. Our objective was to formally evaluate how well the RVQP achieved its aim of promoting continuous QI at participating sites using the constructivist grounded theory. Methods: Using a semi-structured interview guide, we employed a maximum variation sampling approach to ensure diverse representation across several geographical and institutional experiences (e.g., urban vs. rural, academic vs. community). Selected RVQP program leads were invited to participate in a phone interview to yield maximal insight, additionally using a snowball sampling approach to reach non-lead physicians to capture the penetration of the program. Interviews were conducted until thematic saturation was reached and no new insights were gleaned. Interviews were initially cross-performed by two members of the research team, recorded, transcribed, and de-identified. Data analysis was conducted using a constant comparative approach through the development of a coding framework and triangulation with the respondents’ ED setting. We then grouped, compared and refined our analytic categories through an inductive, iterative approach. Results: Between June and August 2018, we interviewed 32 participants, including 21 RVQP program leads and 11 non-lead physicians, from a total of 23 diverse sites (out of 84). Our analysis suggests that the RVQP provides a structured method for EDs to frame the continuous collection of data in order to channel activities towards quality improvement projects based on identified needs. Success factors included: greater involvement with QI processes prior to the RVQP leading to more openness to improvement, a more collaborative approach to RVQP implementation which led to greater front-line workers’ understanding and engagement, and more resources dedicated to implementing the RVQP as well as tackling the quality issues it identified. Conclusion: This study evaluated the impact of an innovative and large-scale program aimed at improving the culture of quality in Ontario EDs. While the program is still relatively new, early results show that there are key elements of EDs that support building a culture of QI.
LO84: Ready to run the show: development of a new instrument for assessing resident competence in the emergency department
Authors: Cheung W. , Gofton W. , Wood T. , Duffy M. , Dewhirst S. , Dudek N.
Published: May 2019

Innovation Concept: The outcome of emergency medicine training is to produce physicians who can competently run an emergency department (ED) shift. While many workplace-based ED assessments focus on discrete tasks of the discipline, others emphasize assessment of performance across the entire shift. However, the quality of assessments is generally poor and these tools often lack validity evidence. The use of entrustment scale anchors may help to address these psychometric issues. The aim of this study was to develop and gather validity evidence for a novel tool to assess a resident's ability to independently run an ED shift. Methods: Through a nominal group technique, local and national stakeholders identified dimensions of performance reflective of a competent ED physician. These dimensions were included in a new tool that was piloted in the Department of Emergency Medicine at the University of Ottawa during a 4-month period. Psychometric characteristics of the items were calculated, and a generalizability analysis used to determine the reliability of scores. An ANOVA was conducted to determine whether scores increased as a function of training level (junior = PGY1-2, intermediate = PGY3, senior = PGY4-5), and varied by ED treatment area. Safety for independent practice was analyzed with a dichotomous score. Curriculum, Tool or Material: The developed Ottawa Emergency Department Shift Observation Tool (O-EDShOT) includes 12-items rated on a 5-point entrustment scale with a global assessment item and 2 short-answer questions. Eight hundred and thirty-three assessment were completed by 78 physicians for 45 residents. Mean scores differed significantly by training level (p < .001) with junior residents receiving lower ratings (3.48 ± 0.69) than intermediate residents who received lower ratings (3.98 ± 0.48) than senior residents (4.54 ± 0.42). Scores did not vary by ED treatment area (p > .05). Residents judged to be safe to independently run the shift had significantly higher mean scores than those judged not to be safe (4.74 ± 0.31 vs 3.75 ± 0.66; p < .001). Fourteen observations per resident, the typical number recorded during a 1-month rotation, were required to achieve a reliability of 0.80. Conclusion: The O-EDShOT successfully discriminated between junior, intermediate and senior-level residents regardless of ED treatment area. Multiple sources of evidence support the O-EDShOT producing valid scores for assessing a resident's ability to independently run an ED shift.
LO86: Improving time to analgesia administration for musculoskeletal injuries in the emergency department.
Authors: Woolner V. , Ahluwalia R. , Lum H. , Beane K. , De Leon J. , Chartier L.
Published: May 2019

Background: Greater than 80% of patient visits to emergency departments (EDs) are for a pain-related concerns. Approximately 38,000 patients per year have such complaints in our academic hospital ED. 3,300 (8.6%) of those visits are for musculoskeletal (MSK) pain (i.e. back or extremity injury/pain), which are typically triaged as low-acuity presentations, leading to longer times to clinician assessment. Delays to adequate analgesia result in unnecessary suffering, worse patient care and satisfaction, and increased patient complaints. Aim Statement: We aimed to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 minutes) in 9 months’ time (May 2018). Measures & Design: Our outcome measures were TTA (in minutes) and ED length of stay (LOS; in minutes). Process measures included nurses’ use of medical directive and rate of analgesia administration. Balancing measures included patient adverse events and time spent triaging for nurses. We utilized weekly data capture for the Statistical Process Control (SPC) chart, and we used Mann-Whitney U test for our before-and-after evaluation. Utilizing the Model for Improvement, we performed wide stakeholder engagement and root cause analyses, and we created a Pareto chart. This led to our Plan-Do-Study-Act (PDSA) cycles: 1) nurse-initiated analgesia (NIA) at triage; 2) new triage documentation aid for medication administration; 3) quick reference medical directive badge tag for nurses; 4) weekly targeted feedback of the project's progress at clinical team huddle. Evaluation/Results: TTA decrease from 129 minutes (n = 153) to 100 minutes (22.5%; n = 87, p < 0.05). ED LOS decreased from 580 minutes (n = 361) to 519 minutes (10.5%; n = 187; p = 0.77). Special cause variation was identified on the ED LOS SPC chart with eight consecutive points below the midline, after PDSA 1. The number of patients who received any analgesia increased from 42% (n = 361) to 47% (n = 187; p = 0.13). The number of patients who received medications via medical directives increased from 22% (n = 150) to 44% (n = 87; p < 0.001). Balancing measures were unchanged. Discussion/Impact: The significant reduction in the TTA and increase in the use of medical directives in the before-and-after analyses were likely due to our front-line focused improvements and deliberate nursing engagement. With continued success and sustainable processes, we are planning to spread our project to other EDs and broaden our initiative to all pain-related concerns.
LO88: Reducing urine culture testing in the emergency department
Authors: Sheps R. , Kirk K. , Burkoski V. , Shelton D.
Published: May 2019

Background: The Choosing Wisely campaign aims to reduce unnecessary testing. Over testing for urinary tract infections and concomitant overtreatment of asymptomatic bacteriuria is a target of this campaign, aiming to decrease healthcare costs and the risks of side effects such as Clostridium difficile infection, adverse reactions, and antimicrobial resistance. During the study baseline (2017), 95 urine cultures (UC) were sent for every 1000 ED visits (9.5%). Of these, fewer than 20% were positive. Aim Statement: The aim of this improvement initiative was to reduce UC testing in the ED, by 50%, from a baseline average of nearly 100 cultures per 1000 ED patients visits, to 50 cultures per 1000 visits, by May 31st, 2018. Measures & Design: This was an interrupted time series study, analyzed using Statistical Process Control (SPC) methodology. Root cause analysis was performed using an Ishikawa diagram. A Pareto chart was completed via multi-voting. A Driver Diagram was developed using the highest ranked items from the Pareto chart to identify locally relevant and feasible interventions. Interventions 1) Medical directives were modified; Routine paired sending of UC with urinalysis by nurses was removed. 2) Physician Education and implementation of a clinical decision aid (CDA); A CDA was created using PDSA methodology, using an iterative approach from development through implementation. Outcome measure: rate of Urine Cultures sent per 1000 ED patient visits Process measure: percent of positive cultures Balancing measures: rate of 14-day ED return visits and hospital admission for patients diagnosed with UTI/Urosepsis/Pyelonephritis. Evalution/Results: At the study's conclusion, there was a decrease in UC rate, from 95 per 1000 ED visits, to 59 per 1000 ED visits (RR 38%, AR 3.6%) There was evidence of special cause variation on the SPC chart. Positive cultures increased from 19% to 34%. There was no increase in the rate of ED 14-day return visits or hospital admission for patients with a diagnosis of UTI, urosepsis or pyelonephritis. Discussion/Impact: The study interventions of uncoupling routine sending of UA and UC, and physician education and use of a clinical decision aid, effectively decreased the rate of UC testing during the study period. A reduction in inappropriate UC testing is important to limit avoidable patient morbidity and reduce unnecessary health care spending. Further studies are indicated to target interventions on patient subgroups and to reduce unnecessary antibiotic prescriptions.
LO91: Urinary tract infections in the paediatric emergency department: A quality improvement initiative to promote diagnostic and antimicrobial stewardship
Authors: Singh V. , Morrissey L. , Science M. , Ostrow O.
Published: May 2019

Background: Urinary tract infection (UTI) is a common diagnosis in children presenting to the Emergency Department (ED) and often leads to empiric antibiotic treatment prior to culture results. A recent study at our centre found that 47% of children diagnosed with a UTI and discharged on antibiotics had a negative urine culture. None of these patients were notified of the negative result or to discontinue antimicrobial treatment. Aim Statement: The aim of this study was to improve UTI diagnostic accuracy by 50% while promoting antimicrobial stewardship through timely antibiotic discontinuation and standardized antimicrobial treatment for uncomplicated UTIs over the next 12 months. Measures & Design: Three interventions were developed using plan-do-study-act (PDSA) cycles. In collaboration with the hospital's Choosing Wisely campaign and antimicrobial stewardship program, an evidence-based empiric UTI diagnostic algorithm was created to aid with diagnostic decision-making and reduce practice variation. A daily call-back system was also implemented for urine cultures where patients who had a negative urine culture were contacted to stop antibiotics. Lastly, a practice alert was integrated in the EMR as a reminder of appropriate antimicrobial prescription duration. The main outcome measures were the percentage of inappropriately diagnosed UTIs and percentage with timely antimicrobial discontinuation. Process measures included antibiotic days saved, treatment duration, and physician adherence to the algorithm. As a balancing measure, positive urine cultures were reviewed to assess accuracy of the algorithm to detect UTIs and potential harm from delayed UTI diagnoses. Evaluation/Results: Early results from the 530 children included in the analysis demonstrated a 14% reduction in inappropriate UTI diagnoses. With the initiation of the call-back system, the antibiotic days saved increased from 0 to 495 days. Call-backs for negative cultures increased from 0% to 68% of the time. Of those positive cultures with a missed UTI diagnosis, only 5 patients in 5 months had a return visit within 72 hours and none required admission. Discussion/Impact: Appropriate diagnosis and treatment of UTIs in our ED has improved with the implementation of a diagnostic algorithm. A larger impact is anticipated once the algorithm is embedded in the EMR as a form of decision support, but these changes take time to implement. Although labour intensive, the call-back system has greatly impacted the antimicrobial days saved and reduced risk for harm in this population.
LO92: Improving patient communication in an emergency department's rapid assessment zone
Authors: Taher A. , Webster Magcalas F. , Woolner V. , Casey S. , Davies D. , Chartier L.
Published: May 2019

Background: Emergency Department (ED) communication between patients and clinicians is fraught with challenges. A local survey of 65 ED patients revealed low patient satisfaction with ED communication and resultant patient anxiety. Aim Statement: To increase patient satisfaction with ED communication and to decrease patient anxiety related to lack of ED visit information (primary aims), and to decrease clinician-perceived patient interruptions (secondary aim), each by one point on a 5-point Likert scale over a six-month period. Measures & Design: We performed wide stakeholder engagement, surveyed patients and clinicians, and conducted a patient focus group. An inductive analysis followed by a yield-feasibility-effort grid led to three interventions, introduced through sequential and additive Plan-Do-Study-Act (PDSA) cycles. PDSA 1: clinician communication tool (Acknowledge-Empathize-Inform [AEI] tool), based on survey themes and a literature review, and introduced through a multi-modal education approach. PDSA 2: patient information pamphlets developed with stakeholder input. PDSA 3: new waiting room TV screen with various informational ED-specific videos. Measures were conducted through anonymous surveys: Primary aims towards the end of the patient ED stay, and the secondary aim at the end of the clinician shift. We used Statistical Process Control (SPC) charts with usual special cause variation rules. Two-tailed Mann-Whitney tests were used to assess for statistical significance between means (significance: p < 0.05). Evaluation/Results: Over five months, 232 patient and 104 clinician surveys were collected. Wait times, ED processes, timing of typical steps, and directions were reported as the most important communication gaps, they and were included in the interventions. Patient satisfaction improved from 3.28 (5 being best, all means; n = 65) to 4.15 (n = 59, p < 0.0001). Patient anxiety improved from 2.96 (1 being best; n = 65) to 2.31 (n = 59, p < 0.01). Clinician-perceived interruptions went from 4.33 (1 being best; n = 30) to 4.18 (n = 11, p = 0.98). SPC charts using Likert scales did not show special cause variation. Discussion/Impact: A sequential, additive approach undertaken with pragmatic and low-cost interventions based on both clinician and patient input led to increased patient satisfaction with communication and decreased patient anxiety due to lack of ED visit information after PDSA cycles. These approaches could easily be replicated in other EDs to improve the patient experience.
MP09: Critical care skills training day for emergency medicine residents: A curriculum in evolution
Authors: Riggs J. , Gray S. , McGowan M. , Petrosoniak A.
Published: May 2019

Introduction: Emergency medicine (EM) residents are expected become proficient in a number of rarely performed, high risk procedures. We developed Critical Care Skills Training Day for senior FRCP and CCFP EM residents at a single university program to fill a gap in resident confidence with these procedures. The day applies principles of deliberate practice with focused feedback using simulation-based training for several rarely performed procedures including thoracotomy, fibre-optic intubation, pericardiocentesis, resuscitative hysterotomy and central line insertion. The objectives of this work was to improve the residents’ scores of self-perceived comfort independently performing these procedures by completion of the training day. Methods: Clinician educators, residency program directors and simulation specialists designed and taught the curriculum. We used pre- and post-training day surveys blending Likert, multiple choice and free text comments to measure comfort performing each procedure, overall satisfaction and usefulness of this training. Descriptive statistics were used to analyze results. Pre-post differences were assessed using paired sample T-tests. Comments and themes from course evaluations were used to make yearly iterative changes. Results: A total of 95 residents completed the curriculum between 2016-2018. 89 completed evaluations (93%). Residents reported significant (p < 0.05) improvement in comfort independently performing fibre optic intubation, thoracotomy and central line insertion. The day was rated very highly, 9.4/10 (SD, 0.72), over 3 years. Feedback was positive with participants identifying opportunities for repeated practice, feedback from instructors and practical tips to improve performance as valuable aspects. Iterative changes were made yearly in response to resident feedback including introduction of new procedures, incorporating skills into sim-based cases, and different training models for skill training. Conclusion: Critical Care Skills Training Day for EM residents was created using the principle of deliberate practice to fill a perceived gap in resident training. Residents who completed the annual curriculum showed a marked increase in comfort independently performing several of the procedures. Ongoing challenges include the length of the day, economies of scale, and training models available for the rare procedures. Future directions include the integration of longitudinal objective performance evaluations to align with the competency by design curriculum.
MP23: Giving medical students what they deserve - a rigorous, equitable and defensible CaRMS selection process
Authors: Paterson Q. , Hartmann R. , Woods R. , Martin L. , Thoma B.
Published: May 2019

Innovation Concept: The fairness of the Canadian Residency Matching Service (CaRMS) selection process has been called into question by rising rates of unmatched medical students and reports of bias and subjectivity. We outline how the University of Saskatchewan Royal College emergency medicine program evaluates CaRMS applications in a standardized, rigorous, equitable and defensible manner. Methods: Our CaRMS applicant evaluation methods were first utilized in the 2017 CaRMS cycle, based on published Best Practices, and have been refined yearly to ensure validity, standardization, defensibility, rigour, and to improve the speed and flow of data processing. To determine the reliability of the total application scores for each rater, single measures intraclass correlation coefficients (ICCs) were calculated using a random effects model in 2017 and 2018. Curriculum, Tool or Material: A secure, online spreadsheet was created that includes applicant names, reviewer assignments, data entry boxes, and formulas. Each file reviewer entered data in a dedicated sheet within the document. Each application was reviewed by two staff physicians and two to four residents. File reviewers used a standardized, criterion-based scoring rubric for each application component. The file score for each reviewer-applicant pair was converted into a z-score based on each reviewer's distribution of scores. Z-scores of all reviewers for a single applicant were then combined by weighted average, with the group of staff and group of residents each being weighted to represent half of the final file score. The ICC for the total raw scores improved from 0.38 (poor) in 2017 to 0.52 (moderate) in 2018. The data from each reviewer was amalgamated into a master sheet where applicants were sorted by final file score and heat-mapped to offer a visual aid regarding differences in ratings. Conclusion: Our innovation uses heat-mapped and formula-populated spreadsheets, scoring rubrics, and z-scores to normalize variation in scoring trends between reviewers. We believe this approach provides a rigorous, defensible, and reproducible process by which Canadian residency programs can appraise applicants and create a rank order list.
MP30: Implementing buprenorphine/naloxone in emergency departments for opioid agonist treatment: a quality improvement initiative
Authors: McLane P. , Scott K. , Suleman Z. , Deol J. , Fanaeian J. , Olmstead A. , Ross M. , Hair H. , Holroyd B. , Lang E. , Biggs C. , Ghosh M. , Tanguay R. , Fisher A. , Fielding S.
Published: May 2019

Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.
MP34: Elder abuse in the emergency department: a systematic scoping review
Authors: Mercier E. , Nadeau A. , Brousseau A. , Emond M. , Lowthian J. , Berthelot S. , Costa A. , Mowbray F. , Melady D. , Cameron P.
Published: May 2019

Introduction: This systematic scoping review aims to synthetize the available evidence on the epidemiology, risk factors, clinical characteristics, screening tools, prevention strategies, interventions and knowledge of health care providers regarding elder abuse in the emergency department (ED). Methods: A systematic literature search was performed using three databases (Medline, Embase and Cochrane Library). Grey literature was scrutinized. Studies were considered eligible when they were observational studies or randomized control trials reporting on elder abuse in the prehospital and/or ED setting. Data extraction was performed independently by two researchers and a qualitative approach was used to synthetize the findings. Results: A total of 443 citations were retrieved from which 58 studies published between 1988 and 2018 were finally included. Prevalence of elder abuse following an ED visit varied between 0.01% and 0.03%. Reporting of elder abuse to proper law authorities by ED physicians varied between 2% to 50% of suspected cases. The most common reported type of elder abuse detected was neglect followed by physical abuse. Female gender was the most consistent factor associated with elder abuse. Cognitive impairment, behavioral problems and psychiatric disorder of the patient or the caregiver were also associated with physical abuse and neglect as well as more frequent ED consultations. Several screening tools have been proposed, but ED-based validation is lacking. Literature on prehospital- or ED-initiated prevention and interventions was scarce without any controlled trial. Health care providers were poorly trained to detect and care for older adults who are suspected of being a victim of elder abuse. Conclusion: Elder abuse in the ED is an understudied topic. It remains underrecognized and underreported with ED prevalence rates lower than those in community-dwelling older adults. Health care providers reported lacking appropriate training and knowledge with regards to elder abuse. Dedicated ED studies are required.
MP40: Psychological distress in patients following pulmonary embolism diagnosis
Authors: Tran A. , Redley M. , de Wit K.
Published: May 2019

Introduction: Pulmonary embolism (PE) is a treatable condition, with a low mortality rate (of around 1% in those who are diagnosed with the condition). The risk of recurrent PE is well managed with long term anticoagulation. Past literature suggests that patients who are diagnosed with PE can go on to experience existential anxiety and symptoms suggestive of post-traumatic stress disorder (PTSD). This study aimed to evaluate the mental and emotional experiences of PE patients through the lens of PTSD, and the factors involved in psychological distress following a PE diagnosis. Methods: Semi-structured interviews were conducted with PE patients at the Juravinski Hospital thrombosis clinic in Hamilton, Ontario. Interview questions were based on DSM-5 criteria of PTSD and relevant existing literature. The transcripts were analyzed by two researchers based on an approach that considers both the content of patients’ accounts as well as the way that patients choose to interpret and deliver those accounts, to develop major themes associated with psychological distress. Results: A total of 37 patients, ranging from 28 to 85 years of age, were interviewed. The patients’ accounts suggested that the manner in which a PE diagnosis was delivered by an emergency physician was a significant factor in the degree to which they experienced psychological distress. For example, patients reported focusing on words suggesting that they were ‘a ticking time-bomb’ or that ‘a lot of people don't get through this,’ which introduced a degree of panic. A number of patients continued to focus on these words, months or years after their diagnosis. Some feared that they could have recurrent PE which could lead to death. Diagnoses that were delivered calmly with thorough explanations of why a patient experienced PE-related symptoms and how they will be treated, helped to minimize any subsequent anxiety. Patients initially misdiagnosed with an alternative condition in the ED also expressed feelings of anxiety and distress. The presence of physically and mentally distressing symptoms was also a factor which contributed to mental distress and anxiety regarding a PE recurrence. Conclusion: Caution should be taken in the delivery of PE diagnosis in the emergency department. Over-emphasis on the severity and life-threatening nature of PE should be avoided to reduce psychological distress.
MP44: Emergency department perceptions of routine in-situ simulation
Authors: Cox C. , Stewart S. , Patrick L. , Sowers N.
Published: May 2019

Introduction: Emergency Department (ED) health care professionals are responsible for providing team-based care to critically ill patients. Given this complex responsibility, simulation training is paramount. In situ simulation (ISS) has many cited benefits as a training strategy that targets on-duty staff and occurs in the actual patient environment. Several evidence-based frameworks identify staff buy-in as essential for successful ISS implementation, however, the attitudes of interdisciplinary front-line ED staff in this regard are unknown. The purpose of this study is to identify contextual trends in interdisciplinary opinions on routine ISS in the ED. Methods: Qualitative and quantitative review, exploring the self-reported attitudes of interdisciplinary ED staff: before, during and after the implementation of a routine ISS pilot program (5 sessions in 5 months) at the Charles V Keating Emergency and Trauma Center in Halifax from Feb-Nov, 2018. Results: 149 surveys were received. Baseline support for ISS was high; 83% of respondents believed that the advantages of ISS outweigh the challenges and 47% favoured simulation in the ED, relative the sim bay (26%) and 28% were indifferent. The attitudes of direct participants in ISS were very positive, with 88% believing that the benefits outweighed the challenges after participation and 91% believing that they personally benefited from participating. A department wide post-ISS pilot survey suggested a slight decrease in support. Support for ISS dropped from 83% to 67%, a statistically insignificant reduction (p = 0.098) but a sizeable change that warrants further investigation. Most notably respondents reported increased support for simulation training in a simulation bay relative to ISS in the ED. Respondents still regarded simulation highly overall. Interestingly, when the results were stratified by position, staff physicians were the least positive. Conclusion: Pre-pilot or baseline opinions of ISS were very positive, and participants all responded positively to the simulations. This study generates valuable insight into the perceptions of interdisciplinary ED staff regarding the implementation and perceived impact of routine ISS. This evidence can be used to inform future programming, though further investigation is warranted into why opinions post-intervention may have changed at the department level.