bluuebunny/crossref_metadata_2025 huggingface dataset:
P129: The Calgary Stampede: effects on emergency and urgent care department utilization during a Canadian mass gathering
Authors: Wong C. , Qian H. , McRae A. , Li Y.J. , Wang D.
Published: May 2017

Introduction: The Calgary Stampede is a two-week mass gathering occurring annually in July. Clinicians have anecdotally noted increases in emergency department (ED) and urgent care (UC) visits, especially for complaints related to substance misuse and violence. Our objectives were: 1) to determine if there is an increase in overall visits to EDs and UCs during the Stampede, and 2) to determine if there are increases in presentations related to trauma, violence, or intoxication. Methods: This observational study used prospectively collected administrative data from five EDs and two UCs in Calgary. For the years 2013 to 2016, daily average data during Stampede dates were compared to the data from the 21 days immediately preceding and following the event. Dates were selected to incorporate a similar proportion of weekends and weekdays in the Stampede and non-Stampede periods. The primary outcome was daily average ED and UC utilization. Secondary outcomes included time of arrival, utilization by demographic groups, complaint category at triage, or International Statistical Classification of Diseases, 10th revision (ICD-10) diagnosis. Results: The study period included 263 380 individual ED and UC visits (34 492 Stampede and 228 888 non-Stampede visits). Daily average ED and UC visits increased by 2.1% (p<0.0001) during the Stampede period. Increases in utilization were identified in specific subgroups: male, ambulance arrival, and nighttime arrival between 2000 and 0400 (all p<0.05). The Stampede period saw a marked increase in CTAS 1 visits (16.2%, p<0.01), triage complaints of lacerations (12.4%, p<0.0001) and blunt trauma (19.4%, p<0.0001), and the ICD-10 diagnosis of substance misuse (23.9%, p=0.01). Visits triaged to the minor treatment areas increased by 9.5% (p<0.0001), again most markedly at night (15.3%, p<0.0001).No differences were detected for triage complaints of altered level of consciousness, sexual assault, head or neck injury, limb injury, or social problems. Conclusion: The Calgary Stampede provokes appreciable changes in overall ED and UC utilization, with marked increases in nighttime visits, visits by men, trauma or substance abuse-related complaints, and minor treatment visits. This data may be useful in manpower planning to ensure optimal patient flow and service delivery during mass gatherings.
CAEP 2016 Academic Symposium: How to have an impact as an emergency medicine educator and scholar
Authors: Frank Jason R. , Cheung Warren J. , Sherbino Jonathan , Primavesi Robert , Woods Robert A. , Bandiera Glen , LeBlanc Constance
Published: May 2017

Background

In a time of major medical education transformation, emergency medicine (EM) needs to nurture education scholars who will influence EM education practice. However, the essential ingredients to ensure a career with impact in EM education are not clear.

Objective

To describe how to prepare EM educators for a high-impact career.

Methods

The Canadian Association of Emergency Physicians (CAEP) Academic Section commissioned an “Education Impact” working group (IWG) to guide the creation of consensus recommendations from the EM community. EM educators from across Canada were initially recruited from the networks of the IWG members, and additional educators were recruited via snowball sampling. “High impact educators” were nominated by this network. The high impact educators were then interviewed using a structured question guide. These interviews were transcribed and coded for themes using qualitative methods. The process continued until no new themes were identified. Proposed themes and recommendations were presented to the EM community at the CAEP 2016 Academic Symposium. Feedback was then incorporated into a final set of recommendations.

Results

Fifty-five (71%) of 77 of identified Canadian EM educators participated, and 170 names of high impact educators were submitted and ranked by frequency. The IWG achieved sufficiency of themes after nine interviews. Five recommendations were made: 1) EM educators can pursue a high impact career by leveraging either traditional or innovative career pathways; 2) EM educators starting their education careers should have multiple senior mentors; 3) Early-career EM educators should immerse themselves in their area of interest and cultivate a community of practice, not limited to EM; 4) Every academic EM department and EM teaching site should have access to an EM educator with protected time and recognition for their EM education scholarship; and 5) Educators at all stages should continuously compile an impact portfolio.

Conclusions

We describe a unique set of recommendations to develop educators who will influence EM, derived from a consensus from the EM community. EM leaders, educators, and aspiring educational scholars should consider how to implement this guide towards enhancing our specialty’s educational mission.
PL01: Creation of the Canadian Heart Failure Risk Scale for acute heart failure patients
Authors: Stiell I.G. , Clement C.M. , Perry J.J. , Brison R.J. , McRae A. , Rowe B.H. , Borgundvaag B. , Aaron S. , Mielneczuk L. , Calder L. , Brinkhurst J. , Forster A. , Wells G.A.
Published: May 2017

Introduction: Acute heart failure (AHF) is a common, serious condition that frequently results in morbidity and death and is a leading cause for hospital admissions. There is little evidence to guide ED physician disposition decisions for AHF patients. We sought to create a risk-stratification tool for use by ED physicians to determine which AHF patients are at high risk for poor outcomes. Methods: We conducted a prospective cohort study in 9 tertiary hospital EDs and enrolled adult patients presenting with shortness of breath due to AHF. Patients were assessed for standardized clinical and laboratory variables and then followed to determine short-term serious outcome (SSO), defined as death, intubation, myocardial infarction, or relapse requiring admission within 14 days. We identified predictors of SSO by stepwise logistic regression and then rounded beta coefficients to create a risk scale. Results: We enrolled 1,733 patients with mean age 77.1 years, male 54.5%, and initially admitted 50.1%. SSOs occurred in 202 (11.7%) cases (14.0% in those admitted and 9.3% in those discharged from the ED). We created the CHFRS consisting of:1. Initial Assessment a) History of valvular heart disease b) On anti-arrhythmic c) Arrival heart rate ≥ 110d) Treated with non-invasive ventilation2. Investigations a) Urea >12 mmol/L or Cr>150 µmol/L b) Serum CO2>35 mmol/L or pCO2 >60 mmHg (VBG or ABG) c) Troponin >5x Upper Reference Level 3. Fails reassessment after ED treatment:(i) Resting vital signs abnormal, (SaO2 <90% on room air or usual O2, or HR >110, or RR >28); OR(ii) Unable to complete 3-minute walk test. The risk of SSO varied from 5.0% for a score of 0, to 77.4% for a score of 9. Discrimination between SSO and no SSO cases was good with an area under the ROC curve of 0.70 (95% CI 0.66-0.74). There was good calibration between the observed and expected probability of SSO and internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. Conclusion: We have created the CHFRS tool which consists of 8 simple variables and which estimates the short-term risk of SSOs in AHF patients. CHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients. This will ultimately lead to better safety for patients and more efficient use of hospital resources.
PL02: Derivation and validation of a feasible emergency department specific frailty index to predict adverse outcomes
Authors: Brousseau A. , Dent E. , Hubbard R.E. , Melady D. , Émond M. , Mercier E. , Costa A.
Published: May 2017

Introduction: Frailty is an overarching concept in geriatric medicine. However its utility in the emergency department (ED) was not well understood. Objectives were to derive and validate an ED specific frailty index (FI-ED), using a cumulative deficits model; and to evaluate its ability to predict adverse outcomes. Methods: This was a large multinational prospective cohort study using data from: The Management of Older Persons in Emergency Departments (MOPED) and the interRAI study. The FI-ED was derived from the Canadian sample and validated in the multinational sample. Inclusion criteria were all patients ≥75 years old presenting to an ED. The FI-ED used 24 variables identified in the interRAI ED-Contact Assessment tool, a brief focussed geriatric assessment. Its ability to predict adverse outcomes were analysed by logistic regression with odds ratio (OR). Results: There were 3903 participants: 2153 in the derivation sample and 1750 in the validation sample. In the derivation sample, increasing FI-ED was significantly associated with admission (OR 1.43 [95% CI 1.34-1.52]), death in hospital (OR 1.55 [1.38-1.73]), prolonged hospital stay (OR 1.37 [1.22-1.54]), needs for Comprehensive Geriatric Assessment (OR 1.51 [1.41-1.60]) and discharge to long-term care (OR 1.30 [1.16-1.47]). In the validation sample, results were similar except for long-term care disposition (OR 0.84 [0.75 0.85]). Conclusion: The FI-ED conformed to characteristics previously reported in other geriatric populations. It was accurately derived and validated from a brief geriatric assessment feasible in the ED and can be used to predict adverse outcomes.
PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation
Authors: Vaillancourt C. , Charette M. , Sinclair J.E. , Maloney J. , Dionne R. , Kelly P. , Wells G.A. , Stiell I.G.
Published: May 2017

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.
LO02: Heart failure and palliative care in the emergency department
Authors: Lipinski M. , Eagles D. , Fischer L.M. , Mielneczuk L. , Stiell I.G.
Published: May 2017

Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.
LO07: Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial
Authors: Peach M. , Milne J. , Lewis D. , Diegelmann L. , Lamprecht H. , Stander M. , Lussier D. , Pham C. , Henneberry R. , Fraser J. , Howlett M. , Mekwan J. , Ramrattan B. , Middleton J. , van Hoving D.J. , Fredericks D. , Taylor L. , Dahn T. , Hurley S.T. , MacSween K. , Cox C. , Richardson L. , Loubani O. , Stoica G. , Hunter S. , Olszynski P. , Atkinson P.R.
Published: May 2017

Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.
LO08: Effect of an intact “chain of survival” sequence on survival to discharge from out-of-hospital cardiac arrest
Authors: Andrusiek D.L. , Abu-Laban R.B. , Tallon J.M. , Sheps S. , Joseph K.
Published: May 2017

Introduction: The “chain of survival” is a 5-link theoretical construct that has been central to cardiac arrest resuscitation for over 40 years. Although the role of each link has been extensively studied, little is known about the impact of performing the chain of survival in sequence. The purpose of this study was to estimate the proportion of out-of-hospital cardiac arrest (OHCA) responses by Emergency Medical Services (EMS) that had an intact chain of survival sequence response, and the effect of this on survival to hospital discharge. Methods: We conducted a prospective cohort study of adult (>age 20 years) OHCA patients using data collected between 2005-2007 by the Resuscitation Outcomes Consortium (ROC). ROC is a research network involving 10 research sites and 264 EMS agencies across North America. Using routinely collected data, we coded cases as receiving an intact or non-intact chain of survival sequence based on EMS cardio pulmonary resuscitation (CPR), rhythm analysis or defibrillation, epinephrine administration or endotracheal intubation, and transport to a hospital with an electrophysiology lab or percutaneous coronary intervention capability, contingent on the patient’s condition when EMS arrived. Multiple variable logistic regression was performed, adjusting for known (Utstein) survival predictors, to estimate the independent effect of intact chain of survival sequence on survival to hospital discharge. REB approval was obtained. Results: We enrolled12,821 OHCA cases, of which, 29.4% (n=3,773) had an intact chain of survival and 7.6% (n=972) survived to hospital discharge. Cases with an intact chain of survival were younger, and more likely to arrest in public, receive bystander CPR, occur in the USA and specific ROC sites, and had faster EMS response times. The adjusted odds ratio of survival to hospital discharge with an intact chain of survival sequence was 2.4 (95% CI: 2.1-2.8). A sensitivity analysis of 4,056 cases with known timing of endotracheal intubation found a similar adjusted odds ratio of 2.1 (95% CI: 1.6-2.8). Conclusion: Our results indicate that OCHA resuscitation with an intact chain of survival occurs in approximately 1/3 of cases, and results in over a two-fold increase in the odds of surviving to hospital discharge. Initiatives to improve EMS teamwork and increase the proportion of OHCA resuscitation with an intact chain of survival appear to be warranted.
LO09: Assessing the ability of emergency department patients to self-triage by using an electronic questionnaire: a pilot study
Authors: Trivedi S. , Littmann J. , Kapur P. , Betz M. , Stempien J.
Published: May 2017

Introduction: The process of triage is used to prioritize the care of patients arriving in the emergency department (ED). To our knowledge, self-triage has not been previously studied in the general emergency department (ED) setting. In an attempt to test the feasibility of implementing this in the ED, we sought to assess the ability of ED patients to triage themselves using an electronic questionnaire. Methods: This was a prospective observational study. An iPad-based questionnaire was designed with a series of ‘yes’ or ‘no’ answers related to common chief complaints. A score corresponding to a Canadian Triage and Acuity Scale (CTAS) category was assigned based on their answers, without the knowledge of patients or ED staff. These scores were subsequently compared to the official CTAS score assigned by triage nurses. A convenience sample of ambulatory patients arriving at the ED were enrolled over a four week period. Patients arriving by ambulance were excluded. We also sought to assess patients’ ability to predict their ultimate disposition. Results: A total of 492 patients were enrolled. The mean age of enrolled patients was 43.9. Of enrolled patients, 56 (11.4%) were under 20 years old, 168 (34.1%) between ages 20-39, 116 (23.6%) between ages 40-59 and 152 (30.9%) older than 60 years. We had 245 (49.8%) patients identify as male. Patient-determined CTAS scores were as follows: 146 CTAS 1 (26.7%), 66 CTAS 2 (13.4%), 176 CTAS 3 (35.8%) and 104 CTAS 4 and 5 (21.1%). Formal triage CTAS scores were: 47 CTAS 2 (9.6%), 155 CTAS 3 (31.5%), and 290 CTAS 4 and 5 (59%). With our survey tool, 22.2% of patients matched their official triage scores. We found that that 69.9% of participants over-estimated their CTAS score while 7.9% underestimated it. Two hundred and three patients (41.3%) felt that they needed to be admitted. In fact, 73 patients (17.3%) were admitted to hospital. Conclusion: Using an electronic questionnaire, ambulatory patients frequently overestimated the acuity of their presenting complaint. Patients were also not unable to accurately predict their disposition. Further study of different approaches to self-triage is needed before possible implementation in EDs.
LO11: Opiate prescribing in Ontario emergency departments
Authors: Borgundvaag B. , Khuu W. , McLeod S.L. , Gomes T.
Published: May 2017

Introduction: Increased prescribing of high potency opioids has been associated with increasing opioid addiction and linked to serious adverse outcomes including misuse, diversion, overdose and death. Problems related to opioids are a major Canadian public health concern yet few data are available on prescribing in most Canadian provinces. The objective of this study was to describe opioid prescribing in Ontario EDs and patient harms associated with this practice. Methods: We conducted a population-based cohort study among Ontario residents aged 15-64 years who were eligible for public drug coverage between April 2008 and March 2012. Using administrative databases, we identified patients with no opioid use in the past 12 months who received a prescription opioid from an emergency or family physician. Patients were followed for 2 years following their index prescription. The primary outcome was hospital admission for opioid toxicity and secondary outcome was dose-escalation exceeding 200 mg morphine equivalents (MEQ). Results: Of the 77,270 unique patients included, 33,492 (43.3%) and 43,778 (56.7%) prescriptions were issued by emergency physician (EP) and family physicians (FP), respectively. FP patients were older (45.9 vs 41.2 yr, MSD 0.35), had fewer ED visits (0.9 vs 2.3, MSD 0.46), and more FP visits (11.5 vs 8.7 MSD 0.31) in the year prior to their index visit. For combination products, EPs were more likely to prescribe oxycodone compared to FPs (37.2% vs 16.7%, Δ 20.5, 95% CI: 19.9, 21.2). For single agent products, EPs were more likely to prescribe hydromorphone compared to FPs (44.5% vs 21.7%, Δ 22.8, 95% CI: 20.4, 25.2). FPs were more likely to prescribe codeine either as a combination or single agent formulation. EP prescriptions led to significantly more hospital admissions for opioid toxicity (0.5% vs 0.3%, Δ 0.2, 95% CI: 0.1, 0.3), while FP prescriptions more often resulted in dose escalation beyond 200 mg MEQs (0.1% vs 0.7%, Δ 0.6, 95% CI: 0.4, 0.7). Conclusion: A large percentage of opioid-naïve patients receive an initial opiate prescription in the ED, where the use of high potency opioids is much more common, with 1/200 of these patients subsequently hospitalized for opioid toxicity. Creation of a physician accessible provincial registry would be useful to monitor opioid prescribing and dispensing, inform clinical practice, and identify patients at high-risk who may benefit from early interventions.
LO12: The utility of femoral nerve blocks in the emergency department; a national survey of practice
Authors: Ringaert J. , Broughton J. , Pauls M. , Laxdal I. , Ashmead N.
Published: May 2017

Introduction: Approximately 30,000 hip fractures occur annually in Canada, and the incidence will increase with an aging population. Pain control remains a challenge with these patients, as many are elderly and prone to delirium. Regional anesthesia has shown to be very effective with minimal risks, but it is not clear how often emergency physicians are using this technique to provide analgesia for patients with proximal hip fractures. This is the first Canada-wide survey to evaluate the use of regional anaesthesia in the emergency department for hip fractures. It also evaluates physician comfort level with performing these blocks, perceived educational needs in this area, and barriers to performing nerve blocks. Methods: A 13-question survey was sent to 1041 members of the Canadian Association of Emergency Physicians via email in January and February of 2016. Data was collected and analysed using an online collection program called “Survey Monkey”. Ethics approval was obtained through the University of Manitoba Research Ethics Board. Results: 272 Emergency physicians and residents took part in the survey. The majority of respondents (75.9%) choose intravenous opioids as their first line of analgesia and only 7.6% use peripheral nerve blocks (PNB) as their first line choice for analgesia in hip fracture. In response to practitioner comfort with PNBs for hip fractures, most were not at all confident (45.0%) in their ability and many respondents have never performed a nerve block for a hip fracture (53.9%). The most commonly identified barriers to performing PNBs include lack of training, the time to perform the procedure and a lack of confidence. A larger percentage of respondents (34.2%), identified having had no training and no knowledge of how to perform PNBs for hip fractures. Conclusion: The vast majority of Canadian emergency physicians who took part in this survey do not utilize PNBs as a method of pain management for hip fractures. Over half have never performed one of these procedures and many have never received training in how to do so. Future efforts should focus on improving access to education, disseminating information regarding the effectiveness of PNB, and addressing logistical barriers in the ED.
LO14: The CanadiEM Digital Scholars Program: An innovative international digital collaboration curriculum
Authors: Zaver F. , Thomas A. , Shahbaz S. , Helman A. , Kwok E.S. , Thoma B. , Chan T.M.
Published: May 2017

Introduction/Innovation Concept: Digital media are a new frontier in medical education scholarship. Asynchronous education resources facilitate a multi-modal approach to teaching, and allows residents to personalize their learning to achieve mastery in their own time. The CanadiEM Digital Scholars Program is a nationwide initiative that provides residents with practical experiences in creating digital educational materials under the supervision of experts in the field. The program allows for collaboration and access to mentorship from top digital educators from across North America. Methods: Interested residents accepted into the program spent a period of their PGY4 year completing modules developed in the theory and science behind digital education. Four modules, developed in an iterative process, have been built on the topics of podcasting, blogging, digital identity, and patient communication. Each fellow was supervised members of the CanadiEM team, a faculty member from the resident’s home institution, and digital experts from across North America. Curriculum, Tool, or Material: The first fellow completed all aspects of the designed curriculum. Above this, he also engaged in blog content creation, initiated research on digital scholarship, and managed the editorial section of CanadiEM. The second fellow is currently halfway through his year (and is expected to complete the program within the year) and has co-authored 30 blog posts and 53 podcasts in 6 months. Conclusion: The CanadiEM Digital Scholars Program utilizes a novel approach to foster development of digital educators utilizing experts across North America. We have demonstrated the feasibility and sustainability with our initial pilot years. This program is being scaled next year to include two scholars per year, which will facilitate cross-collaboration between the scholars.
LO21: Mentorship in Canadian emergency medicine residency training programs: a needs assessment
Authors: Sutherland K.A. , Pham C. , La Riviere C. , Weldon E.
Published: May 2017

Introduction: Research supports the role of mentors in the personal development and career advancement of medical trainees. Compared to non-mentored peers, mentored residents are nearly twice as likely to describe excellent career preparation and demonstrate objective career success. In prior research, only 65% of training programs in Canada had a mentorship program, and 40% indicated a need for more formal mentorship models. Methods: A needs assessment survey was distributed to RCPSC Emergency Medicine (EM) Program Directors across Canada regarding mentorship available to resident physicians training at their centers. Additionally, all EM resident and staff physicians involved in mentorship were surveyed on their perceptions of current models at their institutions. Both surveys were comprised of binary, open ended, and 5 point likert scale questions. Responses were analyzed using Fisher’s exact test. Results: Eleven Program Directors responded to the survey. Formal mentorship programs were found in 82% of training centers, with 77% of programs instituted within the past 5 years. Half of resident/mentor pairings were based on a combination of identified career goals, participant personality traits, or resident request. Other pairing methods included perceived resident needs or attending physician request. Most meetings are face-to-face, with one program requiring mutual scheduled shifts. Residents identified that mentorship was significantly associated with benefits to career (p=0.0016) and niche (p=0.0019) development. Formal mentorship was felt to have a significant association with resident academic development (p=0.05) and lower rates of burnout (p=0.0018) by staff physicians. Staff mentors also associated a personal development benefit related to involvement in a mentorship relationship (p=0.0355). Conclusion: The majority of EM programs have adopted formal mentorship programs within the past 5 years. Residents and staff identify that mentorship relationships are associated with improved career and niche development as well as academic advancement. Future research will include a before and after study of the implementation of a formal mentorship program within the RCPSC-EM program at the University of Manitoba.
LO23: A brief educational session is effective for teaching emergency medicine residents resuscitative transesophageal echocardiography
Authors: Chenkin J. , Hockmann E.
Published: May 2017

Introduction: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application that has the potential to guide the management of critically ill patients in the emergency department. The objective of this study was to determine the effectiveness of a brief training workshop for teaching a resuscitative TEE protocol to emergency medicine residents using a simulator. Methods: Emergency medicine residents with no prior TEE experience from a university-affiliated hospital were invited to participate in the study. Participants completed a questionnaire and baseline skill assessment using a high-fidelity simulator. The training session included a 20-minute lecture followed by 10 simulated repetitions of a 5-view TEE sequence with instructor feedback. Learning was evaluated by a skill assessment immediately after training and a transfer test 1-2 weeks after the training session. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. The primary outcome of this study was the percentage of successful views before and after training. Secondary outcomes included confidence level, image quality, percentage of correct diagnoses, and efficiency of movement. Assessment scores were compared using a two-tailed t-test. Results: 10 of 11 (91%) of invited residents agreed to participate in the study. Confidence level on a 10-point numeric rating scale (NRS) increased from a baseline of 1.0 (SD 0) to 7.0 (SD 1.9) after training (p<0.01). The mean duration between training and transfer test was 9.6 days (SD 1.9). The percentage of successful views increased from 44% at baseline to 100% after training, and 90% on the transfer test (p<0.01). The mean image quality on a 5-point scale was 2.2 (SD 1.0) at baseline, 3.8 (SD 0.7) after training (p<0.01), and 3.1 (SD 0.6) on the transfer test (p<0.01). The mean number of transducer accelerations were 524 (SD 202) at baseline, 219 (SD 54) after training (p<0.01), and 400 (SD 149) on the transfer test (p=0.13). Participants made the correct diagnosis in 70% of cases on the transfer test. Conclusion: After a brief training session using a simulator, emergency medicine residents were able to generate adequate TEE images on a delayed transfer test. Future studies are needed to determine effective strategies for maintaining motion efficiency and imaging quality.
LO25: How safe are our pediatric emergency departments? A multicentre, prospective cohort study
Authors: Plint A. , Calder L. , Cantor Z. , Aglipay M. , Stang A.S. , Newton A.S. , Gouin S. , Boutis K. , Joubert G. , Doan Q. , Dixon A. , Porter R. , Sawyer S. , Bhatt M. , Farion K. , Crawford T. , Dalgleish D. , Johnson D.W. , Klassen T. , Barrowman N. ,   for Pediatric Emergency Research Canada
Published: May 2017

Introduction: Data regarding adverse events (AEs) (unintended harm to the patient from health care provided) among children seen in the emergency department (ED) are scarce despite the high risk setting and population. The objective of our study was to estimate the risk and type of AEs, and their preventability and severity, among children treated in pediatric EDs. Methods: Our prospective cohort study enrolled children <18 years of age presenting for care during 21 randomized 8 hr-shifts at 9 pediatric EDs from Nov 2014 to October 2015. Exclusion criteria included unavailability for follow-up or insurmountable language barrier. RAs collected demographic, medical history, ED course, and systems level data. At day 7, 14, and 21 a RA administered a structured telephone interview to all patients to identify flagged outcomes (e.g. repeat ED visits, worsening/new symptoms, etc). A validated trigger tool was used to screen admitted patients’ health records. For any patients with a flagged outcome or trigger, 3 ED physicians independently determined if an AE occurred. Primary outcome was the proportion of patients with an AE related to ED care within 3 weeks of their ED visit. Results: We enrolled 6377 (72.0%) of 8855 eligible patients; 545 (8.5%) were lost to follow-up. Median age was 4.4 years (range 3 months to 17.9 yrs). Eight hundred and seventy seven (13.8%) were triaged as CTAS 1 or 2, 2638 (41.4%) as CTAS 3, and 2839 (44.7%) as CTAS 4 or 5. Top entrance complaints were fever (11.2%) and cough (8.8%). Flagged outcomes/triggers were identified for 2047 (32.1%) patients. While 252 (4.0%) patients suffered at least one AE within 3 weeks of ED visit, 163 (2.6%) suffered an AE related to ED care. In total, patients suffered 286 AEs, most (67.9%) being preventable. The most common AE types were management issues (32.5%) and procedural complications (21.9%). The need for a medical intervention (33.9%) and another ED visit (33.9%) were the most frequent clinical consequences. In univariate analysis, older age, chronic conditions, hospital admission, initial location in high acuity area of the ED, having >1 ED MD or a consultant involved in care, (all p<0.001) and longer length of stay (p<0.01) were associated with AEs. Conclusion: While our multicentre study found a lower risk of AEs among pediatric ED patients than reported among pediatric inpatients and adult ED patients, a high proportion of these AEs were preventable.
LO28: The Featured Leadership & Organization Workplace (FLOW) Hacks Series: Using the FOAMed domain for knowledge exchange and transfer of emergency department quality improvement projects
Authors: Savage D.W. , Thoma B. , Chan T.M.
Published: May 2017

Introduction/Innovation Concept: Emergency departments (ED) across Canada have experienced increased patient volumes and greater demands on resources. Quality improvement (QI) projects have become common in the ED with the goal of providing better and more efficient care. These projects typically attempt to improve resource utilization or patient experience. Unfortunately, the opportunity to share and exchange information among physicians about QI projects is limited. The Free Open Access Medical Education (FOAMed) domain provides a good opportunity for physicians to share their successes and challenges when implementing QI projects. The Featured Leadership & Organizational Workplace (FLOW) Hacks is an ongoing dissemination project hosted on CanadiEM.org that aims to provide ED physicians with a forum for knowledge exchange and transfer. Methods: Emergency physician leaders from across Canada have been recruited to share their QI experiences. The FLOW Hacks are summarized as a standardized set of questions that aim to convey the most important aspects of the QI project. The physician responses are published on a monthly basis as a feature on the site. Our objective is to represent EDs from across Canada and of variable size. Curriculum, Tool, or Material: Our standardized questions collect information not only on the innovation and team members but also the methodology used for the QI initiative, the data collected, and the performance measures used to assess the outcome. There is a particular focus placed on the challenges that were encountered in implementing the initiative, how they were overcome, and how they would change their approach if they could redo the project. The goal of this format is to showcase the best QI initiatives in Canada so that others can replicate the work and learn from the challenges and success of the authors. Conclusion: The FLOW Hacks series is an innovative project to disseminate QI projects to emergency physicians and managers. In the next phase of this project we will conduct a qualitative analysis of the published FLOW Hacks to identify the common mistakes and best practices in implementation of QI initiatives.
LO29: ILearnEM.com: a curation of quality FOAM resources to learn the fundamentals of emergency medicine
Authors: Mungham A. , Anjum O. , Lo A. , Rosenberg H.
Published: May 2017

Introduction/Innovation Concept: Free Open Access Medical Education (FOAM) is an emerging movement enabling crowdsourced sharing of vast amounts of medical knowledge on the web, especially in the dynamic field of emergency medicine (EM). However, the wide range of FOAM producers and the lack of organization in published FOAM content results in a challenge for learners to find quality resources that meet their educational needs. ILearnEM addresses this by curating content from popular FOAM sites to provide both new and seasoned learners with an organized, topic-structured EM curriculum. Methods: The resources on ILearnEM.com are drawn from the top 50 scoring websites on the Social Media Index (SMI), an indirect measure of quality and impact for online educational resources. The quality of each individual resource is reviewed by our curators using published Quality Checklists developed specifically for FOAM. Links to the original resources are systematically organized into core EM topics and separated into “Approach to” and “Beyond the Basics” categories. Curriculum, Tool, or Material: Since its launch in February 2016, ILearnEM.com has been distributed to the University of Ottawa medical students and residents, the Canadian CCFP-EM program directors, and through social media. Content on the website is updated every two weeks by our curators through an analysis of recent online publications from each of the top 50 SMI sites. The new resources are selected based on the level of quality and the relevance to the fundamentals of EM. Content updates are announced on social media (Twitter) to further engage learners by identifying the availability of new material. Conclusion: Based on a 10-month traffic analysis, 4234 unique visitors visited ILearnEM.com with an average of 1.9 visits/person and 10.4 pages/visit. Of those responding to an online survey (n=138, response rate=3.3%) visitors were 42.8% (n=59) residents, 29.0% medical students (n=40), 19.6% practicing physicians (n=27), and 8.7% other healthcare professionals (n=12). As one of few sites with an objective for a learner-oriented approach to curating content, ILearnEM will continue to be updated regularly based on user feedback to benefit the fast growing consumer base of medical student and resident learners.
LO30: Using a Massive Online Needs Assessment (MONA) to develop a Free Open Access Medical education (FOAM) curriculum
Authors: Jo D. , de Wit K. , Bhagirath V. , Castellucci L. , Yeh C. , Thoma B. , Chan T.M.
Published: May 2017

Introduction/Innovation Concept: The boom in online educational resources for medical education over the past decade has changed how physicians learn and keep up to date with new literature. While nearly all emergency medicine residents use online resources, few of these resources were designed to target knowledge gaps. Novel methods are required to identify learning needs to allow the targeted development of learner-centered curricula. Methods: A multidisciplinary team attempted to determine the feasibility of conducting a Massive Online Needs Assessment (MONA) to assess the perceived and unperceived educational needs in thrombosis and bleeding. An open, online survey was launched via Google Forms and disseminated using the online educational resource CanadiEM.org and social media platforms Twitter and Facebook with the goal of reaching participants of the Free Open Access Medical education (FOAM) community. Curriculum, Tool, or Material: The survey was designed to identify knowledge gaps and contained demographic, free text, and multiple choice questions. It took individuals approximately 30 minutes to complete and was incentivized with entry into a draw for one of four $250 Amazon Gift cards. Feasibility was defined a priori as 150 responses from at least 4 specialties in 4 or more countries. This sample was deemed the minimum number required to identify knowledge gaps (defined as <50% correct answers). The survey was open from September 20 to December 10, 2016. We received 198 complete responses from 20 countries. Respondents included staff physicians (n=109), residents (n=46), medical students (n=29), nurses (n=8), paramedics (n=4), a pharmacist (n=1) and a physician assistant (n=1). The survey entry page hosted on CanadiEM.org received page views from 866 unique IP addresses. As such, a conservative approximation of the completion rate per unique viewer was 22% (198/866). Conclusion: It is feasible to use a MONA to collect data on the perceived and unperceived needs of an online community. Such needs assessments could be used to make online resources more learner-centered.
LO32: Are EMS offload delay patients at increased risk of adverse outcomes?
Authors: Stewart D. , Wang D. , Lang E. , Innes G.
Published: May 2017

Introduction: ED and hospital overcrowding cause offload delays that remove EMS crews from service and compromise care delivery to patients. Prolonged ED boarding times are associated with increased hospital LOS and patient mortality, but the impact of offload delays has not been studied. Our objective was to determine whether offload delays are associated with adverse system and patient outcomes. Methods: From July 2013 to June 2016, administrative data was collated from four Calgary adult EDs. All CTAS 2 and 3 EMS arrivals were studied. Those assigned an ED care space within 15 minutes were considered controls while those with delays of ≥60-minutes were considered ‘delayed’. Multivariable logistic regression was used to determine propensity scores, which were used to match delayed patients to nearest neighbor controls. Matching variables for propensity modeling included age, sex, CTAS level, ED site, arrival day and time, living situation (homecare/facility vs. independent), complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other) and previous ED use (visits within 1 year). The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality. Results: A total of 111,743 patients were studied: 70711 controls and 41032 delayed (median time to stretcher of 8 vs. 109 minutes). There was significant baseline covariate imbalance: Delayed patients were more likely to be female, older, have lower CTAS acuity, arrive on weekdays and evenings, to have general medical complaints, and to arrive at the slowest offload site. In the unmatched analysis, delayed patients had lower 7-day mortality (2.1% vs. 2.6%), similar 30-day mortality (3.5% vs. 3.6%), and longer hospital LOS (10.3 vs. 9.8 days). In the propensity-matched analysis (41016 patients per group), covariate balance was substantially improved and outcomes differed slightly. Seven and 30-day mortality were essentially unchanged, but between group differences for hospital LOS disappeared (10.3 vs. 10.2 days). Conclusion: Propensity analysis suggests that EMS patients exposed to offload delays have similar 30-day mortality and slightly lower 7-day mortality than patients who receive timely ED access. While offload delays lead to substandard hallway care, patient dissatisfaction, and remove EMS crews from service, the levels of offload delay studied here were not associated with higher mortality or prolonged hospital LOS.