bluuebunny/crossref_metadata_2025 huggingface dataset:
Ermittlung von Kerbfunktionen für ein Trogbrücken‐Detail nach dem Konzept der effektiven Kerbspannungen
Authors: Aigner Francesco , Fink Josef , Schachinger Markus
Published: May 2019

Zu den häufigsten Aufgabenstellungen im Bereich des Eisenbahnbrückenbaus gehört der Ersatz von Brücken im Bereich kleiner und mittlerer Stützweiten, in welchen der größte Anteil der Eisenbahnbrücken fällt. Die zu ersetzenden alten Tragwerke waren in der Regel mit offener Fahrbahn ausgeführt worden, die neuen Tragwerke sollten jedoch eine geschlossene Fahrbahn mit einem Schotterbett aufweisen, dessen Dicke im Anwendungsbereich der ÖBB im Regelfall 55 cm beträgt. Aus diesem Grund und weil die Gradiente meist kaum angehoben werden kann, muss die Bauhöhe der Tragwerke in der Regel radikal beschränkt werden. Für eingleisige Brücken im Stützweitenbereich von 10–25 m und mit extrem geringer Bauhöhe kommen Trogbrücken in Betracht, bei welchen das Fahrbahndeck durch ein 120 mm dickes Stahlgrobblech gebildet wird. Die vorliegende Arbeit widmet sich dem Ermüdungsnachweis der geschweißten Verbindung zwischen der Fahrbahnplatte und den Stegen des Trogquerschnitts.
Brücke über die Salzach bei Kaprun
Authors: Seidl Günter , Mariacher Wolfgang , Schmidt Jürgen , Daßler Mathias
Published: May 2019

Im Zuge der Hochwasserschutzmaßnahmen entlang der Salzach wird zur Überführung der Straße von Zell am See nach Kaprun in Österreich eine neue Brücke mit größerer Stützweite notwendig. Der Ersatzneubau der Brücke über die Salzach bei Mayereinöd ist ein Trogbauwerk in Verbundbauweise, dessen Form funktional entworfen wurde. In Querrichtung werden vorgefertigte π‐Platten mit externer Bewehrung gewählt, um eine große Schlankheit und eine schnelle Bauzeit zu ermöglichen. Die externe Bewehrung wird feuerverzinkt ausgeführt.
Tension‐shear interaction of high‐strength bolts during and after fire
Authors: Lange Jörg , Kawohl Anne
Published: May 2019

Connections in steel structures play an essential role in the structural stability of the entire construction. This is also true in the event of a fire. The difficulty in designing connections for fire lies in the fact that not only material properties, but also loads applied to the connections change depending on temperature. In addition, the temperature‐dependent decrease in the tensile strength of high‐strength bolts does not coincide with the decrease in shear strength. So far, the influence of combined tension and shear loading on high‐strength bolts has not been studied in detail.

This project included carrying out interaction tests on high‐strength bolts of property class 10.9 (fu = 1000 N/mm2). Post‐fire performance was examined in addition to observing the loadbearing behaviour during fire. The examinations were completed with additional material tests. The results were compared with earlier research on the temperature‐dependent loadbearing capacity of high‐strength bolts during and after temperature loading as well as on the loadbearing behaviour of bolts in steel structures under combined tension and shear loads. This investigation contributes to a better understanding of the loadbearing capacity of high‐strength bolts under combined loading during and after a fire.
MOCAPE
Authors: Ruppert Simon , Bollinger Klaus , Grohmann Manfred
Published: May 2019

In 2007 the Austrian architectural firm Coop Himmelb(l)au won an international competition with its design idea for a monolithic, ”slightly twisted“ structure with a multifunctional façade. This design has been largely retained. The organization of the volumes and the urban planning positioning could also be essentially implemented.

As a cultural centre, the building unites two independent institutions under one roof: the Museum of Contemporary Art (MOCA) and the Planning Exhibition (PE). Both institutions are housed in rectangular volumes under a covered plaza. Also included are community areas such as an auditorium, conference rooms, multifunctional exhibition halls and service areas. Ramps and escalators lead from the large entrance area to the main level at +10 m. This marks the starting point for tours of the museums. There is a silvery, shiny, softly shaped ”cloud“ in the centre which accommodates a café, bookstores and a museum shop. It also connects the exhibition rooms over several floors via bridges and ramps.

The transparent façade highlights the main entrance and circulation zone between the two buildings and allows unobstructed views between the inside and outside. The open, column‐free exhibition areas with heights from 6 to 17 m also strengthen the impression of a generous design concept.
The emerging importance of noncoding RNAs in the insecticide tolerance, with special emphasis on Plutella xylostella (Lepidoptera: Plutellidae)
Authors: Vaschetto Luis María , Beccacece Hernán Mario
Published: May 2019

Recently generated high‐throughput sequencing data sets have shed light on the important regulatory roles of noncoding RNA (ncRNA) molecules in the development of higher organisms. Nowadays it is well‐known that regulatory ncRNAs can bind complementary RNA or DNA sequences and recruit chromatin remodelers to selectively modulate gene expression. Consequently, genome sequencing and transcriptomics technologies are now being used to reveal hidden associations among ncRNAs and distinct biological mechanisms. This is the case for the diamondback moth Plutella xylostella, a worldwide pest known to infest cruciferous crops and to display resistance to most insecticides, including Bacillus thuringiensis (Bt) based biopesticides. In P. xylostella, it is thought that ncRNAs could play important roles in both development and insecticide resistance. This review will highlight recent insights into the roles of ncRNAs in P. xylostella and related lepidopterans, and will outline genetic engineering technologies which might be used to design efficient ncRNA‐based pest control strategies.

This article is categorized under:

Regulatory RNAs/RNAi/Riboswitches > Regulatory RNAs
Classical and emerging techniques to identify and quantify localized RNAs
Authors: Taliaferro J. Matthew
Published: May 2019

In essentially every cell, proteins are asymmetrically distributed according to their function. For many genes, this protein sorting problem is solved by transporting RNA molecules encoding the protein, rather than the protein itself, to the desired subcellular location. The protein is then translated on‐site to immediately produce a correctly localized protein. This strategy is widely used as thousands of RNAs localize to distinct locations across diverse cell types and species. One of the fundamental challenges to study this process is the determination of the subcellular spatial distribution of any given RNA. The number of tools available for the study of RNA localization, from classical and state‐of‐the‐art methods for the visualization of individual RNA molecules within cells to the profiling of localized transcriptomes, is rapidly growing. These include imaging‐based approaches, a variety of biochemical and mechanical fractionation techniques, and proximity‐labeling methods. These procedures allow for both the detailed study of the molecular requirements for the localization of individual RNA molecules and computational studies of RNA transport on a genomic scale. Together, they have the ability to allow insight into the regulatory principles that govern the localization of diverse RNAs. These new techniques provide the framework for integrating our knowledge of the regulation of RNA localization with that of other posttranscriptional processes.

This article is categorized under:

RNA Export and Localization > RNA Localization

RNA Interactions with Proteins and Other Molecules > Protein–RNA Interactions: Functional Implications

RNA Methods > RNA Analyses in Cells
A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery
Authors: Eryigit Özgür , van de Graaf Floyd W. , Lange Johan F.
Published: May 2019

Background

Proper documentation is an essential part of patient safety and quality of care in the surgical field. Surgical procedures are traditionally documented in narrative operative reports which are subjective by nature and often lack essential information. This systematic review will analyze the added value of the newly emerged synoptic reporting technique in the surgical setting.

Methods

A systematic review was conducted to compare the completeness and the user‐friendliness of the synoptic operative report to the narrative operative report. A literature search was performed in EMBASE, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, and Google Scholar for studies published up to April 6, 2018. The Newcastle–Ottawa Scale was utilized for the risk of bias assessment of the included articles. PROSPERO registration number was: CRD42018093770.

Results

Overall and subsection completion of the operative report was higher in the synoptic operative report. The time until completion of the operative report and the data extraction time were shorter in the synoptic report. One exception was the specific details section concerning the operative procedure, as this was generally reported more frequently in the narrative report. The use of mandatory fields in the synoptic report resulted in more completely reported operative outcomes with completion percentages close to 100%.

Conclusions

The synoptic operative report generally demonstrated a higher completion rate and a much lower time until completion compared to the traditional narrative operative report. A hybrid approach to the synoptic operative report will potentially yield better completion rates and higher physician satisfaction.
Brain atrophy in primary age‐related tauopathy is linked to transactive response DNA‐binding protein of 43 kDa
Authors: Josephs Keith A. , Murray Melissa E. , Tosakulwong Nirubol , Weigand Stephen D. , Knopman David S. , Petersen Ronald C. , Jack Clifford R. , Whitwell Jennifer L. , Dickson Dennis W.
Published: May 2019

Introduction

Primary age‐related tauopathy (PART) is characterized by the presence of neurofibrillary tangles and absent‐minimal β‐amyloid deposition. Transactive response DNA‐binding protein of 43 kDa (TDP‐43), a third protein, has recently garnished a lot of attention in Alzheimer's disease where it is associated with memory loss and amygdala and hippocampal atrophy. We aimed to determine whether TDP‐43 is associated with brain atrophy in PART.

Methods

We assessed the frequency of TDP‐43 in PART and performed voxel‐level analysis in SPM12, as well as region‐of‐interest analysis using linear regression modeling, controlling for variables of interest, to assess for associations between TDP‐43 and brain atrophy.

Results

Of 116 PART cases, 31 (26.7%) had TDP‐43. The presence of TDP‐43 was associated with significantly greater amygdala, hippocampal, and anterior temporal atrophy in both the region‐of‐interest and the voxel level analyses.

Discussion

TDP‐43 is associated with greater brain atrophy in PART.
The analytics lifecycle and the age of innovation
Authors: Jewell Nick
Published: May 2019

A huge number of businesses and organisations of all sizes, from the world's biggest, to small, local companies manage themselves using data to direct their energies. Analytics is at the forefront of modern business management. These are the thoughts that Dave Wells, practice director for data management at Eckerson Group, puts forward in the report ‘The New Analytics Lifecycle’. 1

Organisations of all sizes use data to direct their energies. Analytics is at the forefront of modern business management.

Yet with the continuing snowballing of data resources, access privileges and the technology stack to support them, security and governance have not been kept top of mind within the analytics lifecycle. An organisation needs to understand from top to bottom the data owners, flows and processes it has and then map onto these new ways of doing business that will keep them compliant and customer-centric, says Nick Jewell of Alteryx.
Protecting infrastructure from cyber attack
Authors: Boughton Nick
Published: May 2019

In October 2016, the UK Government launched the National Cyber Security Centre (NCSC), aimed at enhancing the country's ability to deal with cyberthreats. 1 The move outlined the growing importance of cyber security in both the private and the public sector.
LO60: Health research methodology education in Canadian emergency medicine residency programs: a national survey of curriculum assessment
Authors: Wang A. , Van Aarsen K. , Meiwald A. , Yan J.
Published: May 2019

Introduction: With a shift towards competency-based medical education, it is crucial to not only emphasize learner abilities such as clinical skills but also leadership in the conduct of research. Though the Royal College of Physicians and Surgeons of Canada's (RCPSC) training objectives for Emergency Medicine (EM) residents state that the specialist physician be able to describe the principles of research, the research methodology curriculum across EM training programs in Canada is likely variable. The primary goal of this study was to describe the variability of research methodology teaching among RCPSC-EM residency programs. Methods: An electronic survey was distributed to English-speaking RCPSC-EM program directors (PDs) and EM residents. The survey investigated residents' and PDs’ thoughts on the adequacy of their local curriculum and asked them to quantify their research methodology teaching. The primary outcome was the frequency and content of current research methodology and research ethics teaching as well as a description of scholarly project requirements of EM residency programs across Canada. The data was presented with simple descriptive statistics. Results: 79 EM residents and 7 PDs responded (response rate 22.3% and 58.3%, respectively). All 7 PDs indicate having a research methodology curriculum while 71.6% of residents are aware of this curriculum. Only 57.1% of PDs report having formal assessments. Most programs (71.4%) teach via small groups while 28.6% of programs use large group sessions. Residents identify teaching as led by research staff (68.9%), staff physicians (60%), and EM researchers (57.8%), while only 17.8% use outside educators. Students noted various modalities of curriculum feedback such as online surveys, weekly forms, and verbal feedback. Regarding the strength of the curricula, 85.7% of PDs believed their curriculum prepares residents for board exams, while only 62.2% of residents felt similarly. When asked about using a standard web-based curriculum module if available, 60.5% of residents responded in favour. Conclusion: This study demonstrates that EM residency programs across Canada vary with respect to research methodology curriculum and discrepancies exist between residents’ and program directors’ perceptions of the curriculum. Given the lack of a standardized research methodology curriculum for these residency programs, there is an opportunity for curriculum development to improve training in research methodology.
LO61: A national needs assessment on quality improvement and patient safety education in Canadian emergency medicine residency programs
Authors: Trivedi S. , Hartmann R. , Hall J. , Nasser L. , Levac-Martinho O. , Porplycia D. , Kwok E. , Chartier L.
Published: May 2019

Introduction: Quality improvement and patient safety (QIPS) are increasingly recognized as integral to the provision and advancement of emergency medicine (EM) care. In 2015, QIPS were added to the Canadian Medical Education Directives for Specialists (CanMEDS) framework. However, the level of QIPS education and support that Canadian EM residents receive is unknown. In order to better plan national QIPS efforts aimed at enabling EM residents to improve their local care settings, we sought to assess the current state of QIPS education and support in Canadian EM residency programs. Methods: This was a descriptive, cross-sectional electronic survey that was disseminated to all current Canadian EM residents from both Royal College (RC) and Family Medicine - EM training streams. Residents were recruited either directly or through their program's administrative assistant. The survey consisted of multiple-choice, Likert and free-text entry questions. Themes included a) familiarity with QIPS; b) local opportunities for QIPS projects and mentorship; and c) desire for further QIPS education and involvement. The survey was open for a five-week period, with formal reminders after the first and third weeks. Descriptive statistics are reported. Results: 189 (35%) of 535 current EM residents completed the survey, representing all 17 medical schools. 77% of respondents were from the RC stream. 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS. 47.2% of respondents reported “not knowing” or “not having readily available” QIPS projects to participate in their local environment, and 51.5% had equivalent responses with respect to QIPS mentorship opportunities. Only 17.5% of respondents reported that QIPS methodologies were already formally taught in their residency program, and 66.9% indicated a desire for increased QIPS teaching. The majority of respondents were “slightly” (35.9%), “moderately” (23.2%) or “very” (11.3%) interested in becoming involved with QIPS training and initiatives. Conclusion: Responding Canadian EM residents are interested in obtaining greater QIPS education as well as project and mentorship opportunities, but many perceive that they do not have adequate access to these at the current time. As the importance of QIPS increases in the EM community, supporting residents with more robust educational infrastructures may be necessary. Future efforts may include the standardizing of QIPS postgraduate curricula and improving access to QIPS opportunities across the country.
LO62: Intranasal dexmedetomidine for procedural distress in children: a systematic review and meta-analysis
Authors: Spohn J. , Hendrikx S. , Doyon-Trottier E. , Sabhaney V. , Ali S. , Shah A. , Poonai N.
Published: May 2019

Introduction: Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children. However, studies to date have been limited by small samples and imprecise estimates of effect size. We sought to summarize the evidence on the effectiveness of IND for procedures associated with distress in children. Methods: We performed electronic searches of MEDLINE (1946-2018), EMBASE (1980-2018), Google Scholar (2018), CINAHL (1981-2018), Cochrane Central Register of Controlled Trials (2018), 6 clinical trials registries and conference proceedings (2010-2018). Title searches, data abstraction, and risk of bias assessments were performed in duplicate. We included all published and unpublished, randomized and quasi-randomized trials of IND for procedures in children younger than 19 years of age without language restriction. The methodological quality of studies was evaluated using the Cochrane Collaboration's Risk of Bias tool. The primary outcome was the proportion of participants that were deemed to be adequately sedated for the procedure. Results: Of 661 studies, 18 met inclusion criteria. Trials involved 2128 participants, age 1 month - 14 years (836, 39.3% females), who received IND 1 - 4 mcg/kg either by drops (n = 12), atomizer (n = 4), or both (n = 2). 12 trials were eligible for meta-analysis. 13 trials used validated instruments to assess sedation. All studies except one were associated with low or moderate risk of bias. For painful procedures (IV insertion; laceration repair; dental extraction), the pooled OR (95% CI) for adequate sedation and need for additional analgesia was non-significant [1.19 (0.53, 2.65)] and [2.16 (0.62, 7.49)], respectively (n = 5). For non-painful procedures (diagnostic imaging), the corresponding pooled OR (95% CI) favored IND [3.04 (1.58, 5.82)] and [4.44 (2.11, 9.35)], respectively (n = 7). Time to onset and duration of sedation ranged from 13-31 minutes and 41-91.5 minutes, respectively. For adverse effects, the pooled OR (95% CI) was not significantly different between IND and comparators [0.58 (0.22, 1.55] and there were no serious adverse events. Conclusion: IND at doses 1 to 4 mcg/kg are safe and adequately sedate children undergoing non-painful procedures, although the ease of administration must be weighed against the risk of prolonged sedation. Additional trials with larger sample sizes and greater methodologic rigor are needed for painful emergency department procedures such as laceration repair and IV insertion.
LO76: Impact of high emergency department occupancy on time to physician initial assessment: a traffic theory analysis
Authors: Tung S. , Sivilotti M. , Linder B. , Lynch C. , Loricchio D. , Szulewski A.
Published: May 2019

Introduction: Emergency department (ED) congestion is an ongoing threat to quality care. Traditional measures of ED efficiency use census and wait times over extended time intervals (e.g. per year, per day), failing to capture the hourly variations in ED flow. Borrowing from the traffic theory framework used to describe cars on a freeway, ED flow can instead be characterized by three fundamental parameters: flux (patients traversing a care segment per unit time), density (patients in a care segment per unit time), and duration (length of stay in a care segment). This method allows for the calculation of near-instantaneous ED flux and density. To illustrate, we examined the association between stretcher occupancy and time to physician initial assessment (PIA), seeking to identify thresholds where flux and PIA deteriorate. Methods: We used administrative data as reported to government agencies for 115,559 ED visits from April 1, 2014 to March 31, 2016 at a tertiary academic hospital. Time stamps collected at triage, PIA, and departure were verified by nosologists and used to define two care segments: awaiting assessment or receiving care. Using open-source software developed in-house, we calculated flow measures for each segment at 90-minute intervals. Graphical analysis was supplemented by regression analysis, examining PIA times of high (CTAS 1-3) or low (CTAS 4-5) acuity patients against ED occupancy (=density/staffed stretchers) adjusting for the day of the week, season and fiscal year. Results: At occupancy levels below 50%, PIA times remain stable and flux increases with density, reflecting free flow. Beyond 50% occupancy, PIA times increase linearly and flux plateaus, indicating congestion. While PIA times further deteriorate above 100% occupancy, flow is maintained, reflecting care delivery in non-traditional spaces (e.g. hallways). An inflection point where flux decreased with increased crowding was not identified, despite lengthening queues. Conclusion: The operational performance of a modern ED can be captured and visualized using techniques borrowed from the analysis of vehicular traffic. Unlike cars on a jammed roadway, patients behave more like a compressible fluid and ED care continues despite high degrees of crowding. Nevertheless, congestion begins well below 100% occupancy, presumably reflecting the need for stretcher turnover and saturation in subsegmental work processes. This methodology shows promise to analyze and mitigate the many factors contributing to ED crowding.
LO77: Assessing the long-term emergency physician resource planning for Nova Scotia, Canada
Authors: Savage D. , Petrie D.
Published: May 2019

Introduction: Planning for the future emergency physician (EP) workforce will be a significant challenge for decision makers given the rise in emergency department (ED) visits and no concurrent increase in resident positions. EP workforce planning must incorporate physician supply, as well as current and forecasted patient demand. Nova Scotia has undertaken the process of developing a planning model to support policy decision making. We hypothesize that Nova Scotia will require increased resident positions and recruitment from other provinces to meet future patient demand. Methods: We have developed an age structured population model that tracks the number of clinical full-time equivalent (FTE) EPs by their age and shows the “variance” (i.e., supply – demand = variance) over a 30 year planning horizon. This model represents all Level 1, 2, 3, and 4 EDs in Nova Scotia. Current physician supply was calculated based on FTE staffing levels. The current patient demand was based on historical volume and acuity of patients and converted to an FTE demand estimate. Forecasted demand was predicted to increase at an average rate of 0.5% per year. We varied the number of residents trained and the number of EPs recruited from outside the province to examine the effect on the EP workforce. Our initial model will reflect the current training environment and will be referred to as the “current state”. In our 3 scenarios, we increased the number of residents and recruited physicians by 50%, individually and then together. Our outcome measure will be the variance in FTE. Results: The current state showed that the province will have a deficit of 51 FTE EPs over the next 30 years. In scenario 1, a 50% increase in both resident training streams eliminated all variance, while in scenario 2, the increase in recruitment reduced the FTE variance to 34 FTE positions unfilled. In scenario 3, the variance was 0. Conclusion: We feel that this CTAS weighted volumes perspective is important for clinical services planning but the siting, sizing, and synergizing of EDs in a region will involve other inputs. Its important to recognize that we have made the assumption that all physicians starting to work in Nova Scotia will be a 1 FTE. Future iterations will examine the effect of more realistic FTE definitions that account for administrative, teaching and research activities.
LO82: Does triage assignment correlate with outcome for ed patients presenting with chest pain?
Authors: Stackhouse S. , Grafstein E. , Innes G.
Published: May 2019

Introduction: CTAS triage acuity and CEDIS complaint categories are used to prioritize patients for rapid treatment and ED resource allocation. Our objective was to evaluate CTAS and CEDIS validity for risk stratification of ED patients with chest pain using data from two Canadian cities. Methods: This administrative database study included patients seen over a five-year period with a triage complaint of chest pain. Our composite primary outcome included 7-day mortality, cardiac arrest, acute coronary syndrome (ACS) diagnosis (STEMI, NSTEMI, unstable angina{UA}), admission to a critical care unit, or hospitalization with CHF, pulmonary embolism, dysrhythmia, aortic pathology, neurologic or respiratory diagnosis. We dichotomized triage assignments to cardiac vs. noncardiac chest pain and high (CTAS 1,2) vs. low (3,4,5) triage acuity. For our secondary outcome we reported the components of the primary composite outcome. Results: We studied 111,824 patients. The most common overall diagnoses were chest pain NYD (53.8%), ACS (8.9%), musculoskeletal (7.4%), and acute respiratory (5.5%) or GI (5.1%) conditions. Of all patients studied, 85,888 (76.8%) were placed in the “cardiac features” group, and 93,257 (83.4%) fell into high acuity CTAS 1-2. Patients triaged into the “cardiac features” group were more likely to have a composite outcome event (16.6% v. 6.7%; p < 0.001), to be admitted (21.8% v. 9.0%), to require critical care (6.0% v. 0.7%), to receive an ACS diagnosis (11.3% v. 0.9%), and to die within 7 days (0.5% v. 0.2%). Patients in high acuity triage levels were also more likely to have a composite outcome event (15.8% v. 3.3%; p < 0.001), to be admitted (25.4% v. 14.3%), to require critical care (8.2% v. 1.2%), to receive an ACS diagnosis (10.5% v. 0.9%), and to die within 7 days (0.5% v. 0.2%). Conclusion: This study shows that triage assignment is strongly correlated with important patient outcomes and that both the chief complaint and acuity level are powerful risk predictors. These findings may differ at other sites and hospitals should assess and evaluate their data.
LO83: Quick Refresher Sessions (QRS): improving chest compression training for medical students
Authors: Cormier A. , Brennan E.
Published: May 2019

Innovation Concept: High-quality cardiopulmonary resuscitation saves lives; however, current certification standards can leave providers poorly prepared to perform effective chest compressions (CCs). We designed a training program based on the emerging model of skill maintenance through frequent short practice sessions. The ideal frequency of training is currently unknown. Our goal was to provide medical students with access to efficient and effective CC training and to determine an optimal training interval. Methods: Thirty-six second-year medical students were randomized to three groups that trained at different frequencies: once every two months (q2m) (n = 12), once every four months (q4m) (n = 13), and control (n = 11). Study duration was eight months with the intervention groups, q2m and q4m, participating in five and three sessions respectively. The control group was assessed at study start and end, receiving no training in between. At each session, participants completed a one-minute pre-test of CC performance, viewed a one-minute training video, practiced CCs for two minutes with real-time feedback, and completed a one-minute post-test. Performance parameters measured were CC depth, rate, release, and hand positioning. A final “compression score” assessed integrated performance across these parameters and served as our primary outcome. Participants also reported pre- and post-training comfort with performing CCs which served as our secondary outcome. Curriculum, Tool or Material: Our “Quick Refresher Sessions” (QRS) were completed by participants independently without requiring an assessor or facilitator. A manikin with the ability to record and provide real-time quantitative feedback on CC quality was connected to a laptop running a customized interface. Participants typed in an individualized code and were guided through their six-minute sessions automatically. Conclusion: Immediately following the first training session, subjects had significant improvement in compression score (p < 0.001) and skill comfort (p < 0.001). At eight months, both intervention groups, q2m and q4m, achieved higher compression scores than control (p = 0.001 and p = 0.011) and showed greater increase in comfort level (p = 0.002 and p = 0.010). Performance between intervention groups at eight months was not statistically different. Overall, we conclude that independent QRS training every two or four months led to improved CC quality and provider comfort. Future directions include increasing sample size and tailoring training intervals to individual performance.
LO87: Impact of an evidence-based clinical pathway for suspected renal colic in low-risk patients with previous nephrolithiasis on CT utilization and emergency department throughput
Authors: Wu A. , Chenkin J. , Shelton D.
Published: May 2019

Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures & Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.
MP01: Retention and treatment outcomes for patients with substance use disorders treated in a rapid access to addiction medicine clinic
Authors: Wiercigroch D. , Sheikh H. , Hulme J.
Published: May 2019

Introduction: Substance use is prevalent in Canada yet treatment for alcohol use disorder (AUD) and opioid use disorder (OUD) is often inaccessible. Consequently, alcohol and opioid-related diagnoses such as intoxication, withdrawal, and overdose are a major reason for frequent emergency department (ED) visits. The Rapid Access to Addiction Medicine (RAAM) Clinic opened at the University Health Network (UHN) in January 2018 as part of a larger network of clinics in Toronto, and provides rapid, low barrier access to medical treatment for substance use disorder (SUD). Patients attended via self-referral, peer-referral, or referral by the ED, primary care, internal medicine or withdrawal management services. This study describes the demographic profile and short-term outcomes for patients attending a new RAAM clinic in its first 26 weeks of operation, including substance use and treatment retention for AUD and OUD. Methods: We reviewed the electronic medical record at the clinic over its first 26 weeks of operation. We assessed SUD diagnoses, referral source, prescribed medications, self-reported outcomes and retention rates. We calculated descriptive statistics using proportions for categorical variables and means with standard error for continuous variables. A student's t-test was used for all statistical analyses using Microsoft Excel. We reviewed the electronic medical record at the clinic over its first 26 weeks of operation. We assessed SUD diagnoses, referral source, prescribed medications, self-reported outcomes and retention rates. We calculated descriptive statistics using proportions for categorical variables and means with standard error for continuous variables. A student's t-test was used for all statistical analyses using Microsoft Excel. Results: The clinic saw 64 unique patients: 66% had an AUD, 39% had an OUD and 20% had a stimulant use disorder. 55% of patients were referred from outpatient care providers, 30% from the emergency department and 11% from withdrawal management services. 42% remained ongoing patients, 23% were discharged to other care and 34% were lost to follow-up. Gabapentin (38%), naltrexone (33%), and acamprosate (20%) were most frequently prescribed for AUD. Patients with AUD reported a significant decrease (p < 0.05) in alcohol consumption at their most recent visit compared to their initial visit. Most patients (78%) with OUD were prescribed buprenorphine, and most (89%) patients with OUD on buprenorphine had a negative urine screen at their most recent visit. Conclusion: A new RAAM outpatient clinic demonstrates the early success of a low-barrier addictions model in addressing unmet needs in substance use treatment. We see a reduction in both alcohol consumption and opioid use, and increased access to evidence-based pharmacotherapy for SUDs.
MP02: Diagnostic, medical, and surgical interventions that reduce emergency hospital admissions: a systematic review of systematic reviews of 215 randomized controlled trials
Authors: Collins D. , Bobrovitz N. , Fletcher B. , Onakpoya I. , Heneghan C. , Mahtani K.
Published: May 2019

Introduction: Emergency hospital admissions are a growing concern for patients and health systems, globally. The objective of this study was to systematically review the evidence for diagnostic, medical, and surgical interventions that reduce emergency hospital admissions. Methods: We conducted a systematic review of systematic reviews by searching MEDLINE, PubMED, the Cochrane Database of Systematic Reviews, Google Scholar, and grey literature. Systematic reviews of any diagnostic, surgical, or medical interventions examining the effect on emergency hospital admissions among adults were included. The quality of reviews was assessed using AMSTAR and the quality of evidence was assessed using GRADE. The subsequent analysis was restricted to interventions with moderate or high-quality evidence only. Results: 13 051 titles and abstracts and 1 791 full-text articles were screened from which 42 systematic reviews were included. The reviews included an underlying evidence base of 215 randomized controlled trials with 135 282 patients. Of 20 unique diagnostic, medical, and surgical interventions identified, four had moderate (n = 4) or high (n = 0) quality evidence for significant reductions in hospital admissions in five patient populations. These were: cardiac resynchronization therapy for heart failure and atrial fibrillation, percutaneous aspiration for pneumothorax, early/routine coronary angiography for acute coronary syndrome (alone or comorbid with chronic kidney disease), and natriuretic peptide guided therapy for heart failure. Conclusion: We identified four interventions across five populations that when optimized, may lead to reductions in emergency hospital admissions. These finding can therefore help guide the development of quality indicators, standards, or practice guidelines.
MP03: Strategies to minimize impact of electronic health record implementation on emergency department flow
Authors: Grafstein E. , Horak S. , Kung J. , Bonilla J. , Stenstrom R.
Published: May 2019

Introduction: Electronic health record (EHR) implementation can be associated with a slowdown in performance and delayed return to pre go-live productivity. The objective of this study is to describe the impact of a go-live strategy including diversion, public advertising of the go-live, and extra physician staffing to mitigate productivity loss. Methods: Lions Gate Hospital (LGH), an urban community hospital and rural referral centre with 250 beds and 65,000 annual ED visits went live with Cerner HER (Cerner Corporation, Kansas, MO) on April 28, 2018. The implementation included complete electronic ordering and electronic physician documentation. We compared patients seen per hour, time to physician (TTMD), ED length of stay (EDLOS), patients per hour left without being seen (LWBS), and admission rate (AR) for the 6 weeks prior to implementation (Pre), 2 weeks during (Imp), and 6 weeks after (Post) for LGH and a control hospital (Richmond Hospital – comparable in size/acuity) for the same periods. Medians were compared using the Mann-Whitney test for patients/hour, EDLOS and TTMD, and chi-square for AR and LWBS. Results: Patients/hour seen went from 2.1/hour in the pre phase, but dropped to 1.7/hr in the 2 week period following implementation (P < 0.05). During weeks 2-8 post implementation, 2,3 patients per hour were seen (P = 0.38 compared to Pre phase). At the control hospital, patients per hour were comparable across all time periods (Ps > 0.3). Median time to physician was 54, 56, and 54 minutes at LGH for the Pre, Imp, and Post time periods (Ps > 0.3). Median EDLOS was 184, 196, and 184 minutes in the pre, Imp, and post phases (P Imp versus pre = 0.11; Pre versus post = 0.54). LWBS rate was 1.3%, 2.9, and 2.4% (Ps for Imp and Post versus pre <0.05) at LGH, but the pattern was similar for the control hospital (2.9%, 4.1% and 4.0%’ Ps <0.05). There was no significant change in ambulance arrivals or admission rate at either hospital (Ps > 0.2). Conclusion: A deliberate implementation strategy that focuses on ED physician upstaffing and visit diversion can smooth the impact of the implementation of an EHR so that patient care is not impacted significantly. Return to normal productivity occurred by 8 weeks post go-live. We demonstrate a strategy that may support easier implementation at other sites.
MP11: Evaluation of a pharmacist-led antimicrobial stewardship service in a pediatric emergency department
Authors: MacInnis M. , MacMillan K. , Fitzpatrick E. , Hurley K. , MacPhee S. , Matheson K. , Black E.
Published: May 2019

Introduction: We implemented a pharmacist-led antimicrobial stewardship (AMS) service for patients discharged from the pediatric emergency department (PED). This service, supported by a collaborative practice agreement, allows pharmacists to follow up with patients and independently stop, start, or adjust antimicrobial agents based on culture results. The primary objective of our study was to evaluate the impact of this service on the rate of return visits to the PED within 96 hours. The secondary objective was to evaluate the appropriateness of the prescribed antimicrobial agent at follow up. Methods: This study was completed as a retrospective chart review 6 months pre-implementation (January 1st, 2016 to June 31st, 2016) and 6 months post-implementation (February 1st, 2017 to July 31st, 2017) of a pharmacist-led AMS service. A research assistant extracted data from electronic medical records using a standardized data collection form. All patients discharged from the PED with a suspected infection whose cultures fell within the parameters of the collaborative practice agreement were included in this study. Data were reported descriptively and compared using a two-sided chi-square test. Results: This study included 1070 patient encounters pre-implementation and 1040 patient encounters post-implementation of the AMS service. The most commonly reviewed culture was urine (38% pre-implementation and 41% post-implementation). The rate of return visits to the PED within 96 hours was 12.0% (129/1070) pre-implementation vs 10.0% (100/1049) post-implementation phase (p = 0.07). A significantly higher percentage of inappropriate antimicrobial therapy was identified at the time of follow up in the pre-implementation phase (7.0%, 68/975) compared to the post-implementation phase (5.0%, 46/952), p = 0.047. Conclusion: Although this pharmacist-led AMS service did not affect the rate of return visits within 96 hours, it may have led to more judicious use of antimicrobial agents.
MP14: Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: ‘The Ottawa Troponin Pathway’
Authors: Thiruganasambandamoorthy V. , Stiell I. , Chaudry H. , Mukarram M. , Booth R. , Toarta C. , Hebert G. , Beanlands R. , Wells G. , Nemnom M. , Taljaard M.
Published: May 2019

Introduction: Guidelines recommend serial conventional cardiac troponin (cTn) measurements 6-9 hours apart for non-ST-elevation myocardial infarction (NSTEMI) diagnosis. We sought to develop a pathway based on absolute/relative changes between two serial conventional cardiac troponin I (cTnI) values 3-hours apart for 15-day MACE identification. Methods: This was a prospective cohort study conducted in the two large ED's at the Ottawa Hospital. Adults with NSTEMI symptoms were enrolled over 32 months. Patients with STEMI, hospitalized for unstable angina, or with only one cTnI were excluded. We collected baseline characteristics, Siemens Vista cTnI at 0 and 3-hours after ED presentation, disposition, and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (AMI, revascularization, or death due to cardiac ischemia/unknown cause). We analysed cTnI values by 99th percentile cut-off multiples (45, 100 and 250ng/L). Results: 1,683 patients (mean age 64.7 years; 55.3% female; median ED LOS 7 hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI ≤45ng/L; and 58 (3.4%) of the 213 patients with one value≥100ng/L but both <250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one value >45ng/L but both <100ng/L based on 3 or 6-hour cTnI, one patient with Δ<10ng/L and 6 of 19 patients with Δ≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95%CI 96.7-100%) and 94.6% specificity (95%CI 93.4-95.7%). Conclusion: The OTP, using two conventional cTnI measurements performed 3-hours apart, should lead to better identification of NSTEMI particularly those with values >99th percentile cut-off, standardize management and reduce the ED LOS.
MP15: Blood transfusion in upper gastrointestinal bleeding: evaluating physician practices in the emergency department
Authors: Stach J. , Sandha S. , Bullard M. , Halloran B. , Blain H. , Grigat D. , Sandha G. , Lang E. , Veldhuyzen Van Zanten S.
Published: May 2019

Introduction: Acute upper gastrointestinal bleeding (UGIB) is a common presentation to emergency departments (ED). Of these patients, 35-45% receive a blood transfusion. Guidelines for blood transfusion in UGIB have been well established, and recommend a hemoglobin (Hb) level below 70 g/L as the transfusion target in a stable patient. There is no consensus on a transfusion threshold for unstable UGIB. There is limited data regarding physician practices in the ED. The aim of our study is to determine the appropriateness, by expert consensus, of blood transfusions in UGIB in a tertiary care hospital ED. Methods: We retrospectively reviewed patients presenting with UGIB to the University of Alberta Hospital ED in 2016. These patients were then screened for blood transfusions. Data were obtained from the patient records. Chart derived data were verified with records obtained from the blood bank. For each patient, the history, vitals, Glasgow Blatchford Score (GBS), relevant labs, and record of blood transfusions were collected and organized into a case summary. Each patient summary was presented individually to a panel of three expert clinicians (2 Gastroenterology, 1 Emergency Medicine), who then decided on the appropriateness of each blood transfusion by consensus. Results: Blood transfusions (data available 395/400) were given to 51% (202/395) of patients presenting with UGIB. Of these, 86% (174/202) were judged to be appropriate. Of the 395 patients, 34% (135/395) had a Hb of <70 g/L. Of these, 93% (126/135) were transfused, and all of these were considered appropriate. 18% (70/395) had a Hb between 71-80. 74% (52/70) of these patients were given blood, and 79% (41/52) were considered appropriate. 13% (50/395) of the patients had a Hb between 81-90, with 28% (14/50) receiving a transfusion. Of these, 36% (5/14) were deemed to be appropriate. 35% (140/395) of patients had a Hb of >90. 7% (10/140) of these received blood. 20% (2/10) were considered appropriate. Conclusion: The panel of expert clinicians judged 86% of the blood transfusions to be appropriate. All transfusions under the recommended guideline of 70 g/L were considered appropriate. In addition, the majority of transfusions above a Hb of 70 g/L were considered appropriate, but 37% were not. Further studies evaluating the feasibility of current guideline recommendations in an ED setting are required. Educational interventions should be created to reduce inappropriate blood transfusions above a Hb 70 g/L.