bluuebunny/crossref_metadata_2025 huggingface dataset:
P084: Waiting makes me sick: is it time for formal triage in primary care?
Authors: MacKay J. , Atkinson P.R. , Howlett M. , Palmer E. , Fraser J. , Vaillancourt E.
Published: June 2016

Introduction: Patient morbidity and mortality are influenced by delay in access to care and lack of continuity of care. Patients frequently present to the emergency department (ED) for care despite being registered with a primary care (PC) provider. Advanced access is an open scheduling system promoted by the College of Family Physicians of Canada that triages primary care (PC) patients to be seen within 24 hours, reducing care delay. We wished to determine the prevalence of formal triage systems in PC appointment allocation. Methods: We performed linked cross sectional surveys to quantify the number of ambulatory patients presenting to a tertiary urban ED (with an annual census of 56,000 visits) who felt unable to access primary care. PC practices were also surveyed to assess use of formal triage methods and measure access using the metric of time to third next available appointment. Descriptive statistics were calculated. Results: In the patient survey, 381 of 580 patients consented to participate. Of those, 324 patients reported reasons for their ED visit. Perception that wait time for PC was “too long” was reported in 73/324 (23%); 86% reported wait times of greater than 48 hours. The PC practice response rate was 63.8% (46/ 72). The mean time to third next available appointment was 7.7 (95% CI 4.9-10.5) days (median 5 days, range 0-50 days). No PC practice reported utilizing a formal triage system when booking appointments. Conclusion: No primary care practices in the surveyed region used a formal triage system to allocate appointments, despite a range of wait times that extended up to 50 days. The safety of primary care appointment allocation may be improved with introduction of a formal triage system, especially if overall wait times cannot be reduced.
P095: Who, what, where: a critical assessment of helicopter emergency medical services transport and transfer times on patient outcomes at two level 1 trauma centres
Authors: Nolan B. , Ackery A. , Tien H. , Sawadsky B. , Rizoli S. , Mcfarlan A. , Phillips A.
Published: June 2016

Introduction: Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems to expedite transportation to a trauma centre. Ornge is a provincially run, paramedic-staffed HEMS that is responsible for all air ambulance service within Ontario, Canada. They provide transportation for trauma patients through one of three ways: scene call, modified scene call or interfacility transfer. In this study we report the characteristics of patients transported by each of these methods to two level 1 trauma centres and assess for any impact on morbidity or mortality. Methods: A local trauma registry was used to identify all patients transported to our two trauma centres by HEMS over a 36-month period. Data surrounding patient demographic, arrival characteristics, transport times and in-hospital course were abstracted from the registry. Statistical analysis will be used to compare methods of transport and characterize any association between mode of transport and mortality. Results: From January 1st, 2012 to December 31st, 2014 HEMS transferred a total of 911 patients to our trauma centers with an overall mortality rate of 11%. Of these patients 139 were scene calls with a mortality rate of 8%, 333 were modified scene calls with a mortality rate of 14% and 439 were interfacility transfers with a mortality rate of 10%. Conclusion: Identifying any association between the type of HEMS transport and morbidity and mortality, we may be able to predict those that need more urgent transfer to a trauma centre and find ways to decrease our overall pre-trauma center time.
P096: Hospitalselfie: a review of implications and recommendations on patients making video recordings in hospital
Authors: Nolan B. , Ackery A. , Au B.
Published: June 2016

Introduction: Smartphones are everywhere. Recent technological advances allow for instantaneous high quality video and audio recordings with the touch of a button. In Canada, physician smartphone use is highly regulated by provincial legislature and multiple policies have been published from provincial physician colleges and the Canadian Medical Protective Association (CMPA). Patients on the other hand have no such laws to observe. We set out to look at what legislation and policies exist to provide guidance to physicians in two potential scenarios: when a patient requests to record a patient-physician interaction and if a patient surreptitiously records a patient-physician interaction without consent of the physician. Methods: A literature review searching for articles on patient video recordings and patient smartphone use was completed on both Medline and PubMed. Further review of each provincial privacy act and communication with each provincial privacy office was performed. Consultation with each provincial physician college and the CMPA was also done to identify any policies or recommendations to guide physicians. Results: Patients making video recordings do not fall under any provincial privacy law and there are no existing policies from any provincial physician college or the CMPA to provide guidance. Therefore, physicians must rely on their own institution’s policy regarding patient video recording in the health care setting. Be familiar with your institution’s policy. If your institution does not have a policy, create one with the input of appropriate stakeholders. Patients may surreptitiously video record medical interactions without physician consent. Although this may not be permitted under an individual institution’s policy, it is not illegal under the Criminal Code. Thus, it is important to behave in a professional manner at all times and assume you may be recorded at any time. Conclusion: The majority of patients’ recordings will be done without litigious intentions, but rather with the goal of understanding more about their own health and medical care. Unfortunately there are those who will undermine the physician-patient relationship. Physicians cannot allow this to cause distrust in future relationships, nor should it force physicians to practice more defensive medicine. Physicians must continue to practice the art of medicine and accept that “performance” is a part of the job.
P102: TeamSTEPPS: promoting a culture of safety
Authors: Webb A. , Lussier D. , Ngo M. , Klassen J. , Steigerwald R. , Buchel A.
Published: June 2016

Introduction / Innovation Concept: Adverse events due to medical error are a significant source of preventable morbidity and mortality in Canada’s emergency departments. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was introduced in 2006 as a strategy to minimize these errors. Although these strategies have been available and widely implemented in hospitals over the last decade, the optimal method of teaching these tools and strategies has not been elucidated. Methods: We endeavoured to introduce a twelve month longitudinal TeamSTEPPS program to physicians, nurses, and allied health care professionals in a busy tertiary care hospital via a multi-pronged approach consisting of group huddles, props in the department, and several social media strategies. Dedicated observers in the emergency department recorded the use of the strategies by staff members to identify improved and sustained use of TeamSTEPPS behaviours after they were introduced. Curriculum, Tool, or Material: The program that consists of five modules to improve patient safety outcomes: Team structure; Leadership; Situation Monitoring; Mutual support; and Communication. Each module consisted of educational tools including posters in the department explaining the concepts, twice weekly department huddles to discuss the importance of the monthly topic and promote team sharing with real life examples, as well as stimulating and generating discussions around the monthly theme on social media (Facebook, Twitter, and an on-line blog). For several modules, extra prompts, such as I PASS the BATON handover cards were also provided to act as reminder visual cues. The first two modules were rolled out with on-line music videos rewritten to promote the significance of the modules. A team performance observation tool was adopted from the TeamSTEPPS program, and behaviors were evaluated and recorded under the five domains. Conclusion: Although unable to detect a meaningful difference in our pre and post-implementation observations, we present a novel approach to educating a multi-disciplinary team about TeamSTEPPS in a busy emergency department, along with the challenges encountered in this unique area of research, and recommendations for further study to interested parties. The TeamSTEPPS program likely could offer as much to the emergency department as similar programs have to the aviation industry yet it requires extensive investigation within this health care venue.
P103: Emergency medicine as a career choice: what influences medical students throughout their schooling?
Authors: Pianosi K.D. , Hurley K.F.
Published: June 2016

Introduction: Practicing emergency medicine (EM) involves rapid decision-making in an acute setting, broad knowledge and a strong ability to multi-task. Some medical students find these characteristics attractive, while others find them a deterrent. Previous studies have indicated the range of characteristics that interest undergraduate students. No studies have followed students to assess how attitudes towards EM careers evolve over their schooling. Methods: An open-ended survey of medical students’ career interests was distributed at five data-collection points over the four years of undergraduate training from 1999-2006 at Memorial University. Guided by principles of grounded theory the qualitative data was coded to identify key themes and sentinel quotes. Semi-structured interviews with academic emergency physicians at Dalhousie University were then conducted to assess the relevance of these findings to postgraduate training (in progress). These transcripts were analyzed in the same manner as the longitudinal surveys. Results: 1281 surveys were completed by 540 students, with 758 comments about EM. The biggest drawbacks of EM included lack of patient follow-up and lack of experience in EM; the biggest benefits included variety of cases and patients, congruence with previous life experiences, and elective experiences. One major theme was the Certificant of the College of Family Physicians (CCFP) EM training, as it meant a shorter residency that was more transferrable to rural settings. Lifestyle was a prominent theme, seen as positive by some and negative by others. Emergency physicians commented on students’ naivety, especially relating to media and the nature of the work early in their training. Conclusion: Medical students’ opinions of EM tend to shift throughout their schooling, in particular, the perception of the work. Medical students’ perceptions differ significantly from that of experienced emergency physicians, highlighting the need for a greater degree of mentoring. Perceptions of lifestyle in EM are highly variable amongst students, acting as both a benefit and a drawback. Medical schools may be able to improve clinical exposure and provide more informed career counselling with respect to emergency medicine. Residency program directors can consider these findings during recruitment and interviewing to determine whether students have a realistic view of the specialty and career trajectory.
P121: Does test-enhanced learning improve success rates of ultrasound-guided peripheral intravenous insertion? A randomized-controlled trial
Authors: Slomer A. , Chenkin J.
Published: June 2016

Introduction: Optimising teaching techniques when introducing learners to new skills such as ultrasound guided peripheral IV insertion (UGPIV) is essential due to the time and resource intense nature of skills learning. The testing effect has been demonstrated to be effective in improving learner retention, however there is little research evaluating the testing effect on the acquisition of technical skills in medicine. This study aims to determine whether test-enhanced learning improves learner performance of UGPIV. Methods: A prospective randomized control trial is ongoing with medical students on rotation at Sunnybrook Health Sciences Centre. Participants are randomized to one of two study groups, the control group (CG) and the test-enhanced learning group (TEG). Each group receives a teaching session lasting 1.5 hours surrounding ultrasound guidance for peripheral IV insertion. The TEG receives a formal evaluation of the skill during the last 15 minutes of that session, whereas the CG has continued practice time. Subjects in both groups are being evaluated two weeks later to compare skill performance using an objective structured assessment of technical skills. Results: Data collection is ongoing and is expected to be completed with an recruitment of 40 by March 31st. Conclusion: Given the importance and resource intensive nature of technical skill training it is important to have an understanding of the most efficient ways to teach new techniques. The results from this study will help provide evidence on the testing effect as a method of improving competency and retention for ultrasound guided procedures.
P123: Missed fractures on radiographs in a pediatric emergency department
Authors: Smith J. E. , Tse S. , Barrowman N. , Bilal A.
Published: June 2016

Introduction: About 3-8% of fractures are missed in the adult emergency department (ED). No study has examined this in a pediatric ED. Such data is essential to quality improvement. We sought to determine the proportion of missed fractures on x-rays in a pediatric ED, the location of missed fractures and associated factors, and if missed fractures were clinically significant. Methods: We did a retrospective cohort study from Jan 1 to Dec 31, 2013 of 1000 pediatric patients with a fracture on x-ray in our academic pediatric ED. We randomly reviewed radiologist reports to find new fractures. A fracture was missed if identified by the radiologist but not the ED physician. Data was collected on patient, fracture, department and physician characteristics and change in management or complications. Descriptive statistics were used for clinical characteristics. The proportion of missed fractures was computed using the Wilson score method. Factors associated with missed fractures were investigated using chi-squared test. Results: Of 1000 x-rays, 19.4% (95% CI 17.0-22.0%) had at least one fracture missed. However, when possible fractures were removed for further analysis, 13.9% (95% CI 11.7-16.5%) were missed. The bones most associated with missed fractures were pelvis (60%,) carpal (50%,) vertebra (42.9%,) and patella (33.3%) (p<0.001.) However, these accounted for only 12.5% of missed fractures whereas ulna (31.3%,) metatarsal (14.1%,) phalynx of the hand (9.4%,) and fibula (7.8%) accounted for the greatest number of missed fractures. The fracture types most associated with a missed fracture were styloid, Salter-Harris IV, Salter-Harris I, compression, avulsion and buckle (p<0.001.) The presence of multiple fractures was associated with missed fractures (35.0% vs 7.2%, p<0.001) as was older age (11.2 vs 9.5 years, p=0.001). Most missed fractures were not clinically significant (71.9%) but some required splinting or limitation of activities. One had decreased function at 2 months. Conclusion: Overall, the proportion of missed fractures is higher than in adults, stressing difficulties with reading pediatric x-rays. Most missed fractures were not of clinical significance. Carpal, patella, vertebra and pelvis fractures were particularly challenging but were also rare. Ulna, metatarsal, phalynx of the hand and fibula accounted for the greatest number of missed fractures. More education may help improve physician skills in recognizing these fractures.
P129: The impact of high performance physician training on resident wellness and clinical performance
Authors: Sytnik P. , Hussain A. , Brooks J.
Published: June 2016

Introduction / Innovation Concept: There are numerous research studies in the medical literature, which demonstrate how the experience of a medical residency can contribute towards burnout. The escalating performance pressures and expectations during residency training have the potential to negatively impact upon physician health and clinical performance. The purpose of this prospective cohort study was to test the effectiveness of the High Performance Physician (HPP) program among General Surgery residents at the University of Manitoba with regard to burnout and clinical performance. Methods: This program was delivered over a 9-week period. All 26 residents were asked to complete the Maslach Burnout Inventory - Human Services Survey (MBI-HSS). Each resident then participated as the team leader for a 15-minute trauma resuscitation simulation. Three attending physicians from Surgery & Emergency Medicine assessed resident performance and ability to manage work-based stressors. Following the simulation, each resident received a debrief interview. Once the HPP curriculum had been completed, residents took part in a second high fidelity simulation session and again completed the MBI-HSS. Curriculum, Tool, or Material: The HPP program offered through the Department of Emergency Medicine (EM), is a performance enhancement based curriculum. It is designed to equip physicians with mental skills to help optimize focus, arousal control, stress management, communication, and teamwork. Further, to utilize these skills to cope and respond more effectively to the inherent performance pressures that may present within one’s area of specialization. Conclusion: The Emotional Exhaustion domain of the MBI-HSS demonstrated a statistically significant decrease. The other domain scores were not statistically significant. Simulation domain scores did not demonstrate a statistically significant difference in performance between the pre- and post-HPP curriculum simulation sessions. A summative content analysis of the interview data demonstrated that residents believed internal barriers to situational awareness were the most significant impact on performance. Further study is required to determine if differences are seen in long-term follow-up.
P131: Emergency department falls risk management screening tool comparison
Authors: Tomlinson R. , Yokota T. , Jaggi P. , Kilburn C. , Bakken D. , Lipon B.D. , Bullard M.
Published: June 2016

Introduction: Emergency Department (ED) fall risk screening has been newly implemented in Alberta based on Accreditation Canada requirements. Two existing inpatient tools failed to include certain ED risk conditions. One tool graded unconsciousness as no risk for falling, and neither considered intoxication or sedation. This led to the development of a new fall risk management screening tool, the FRM (Tool1). This study compared Tool1 with inpatient utilized Schmid Fall Risk Assessment Tool (Tool2) and the validated Hendrich II Fall Risk Model (Tool3). Methods: Patients (≥17 years old) in a tertiary care adult ED with any of the following; history of falling in the last 12 months, elderly/frail, incontinence, impaired gait, mobility assist device, confusion/disorientation, procedural sedation, intoxication/sedated, or unconscious were included. Forms were randomized to score patients using different paired screening tools: Tool1 paired with either Tool2 or Tool3. Percent agreement (PA) between the tools based on identification of a patient at either risk/no risk for falling; higher PA indicating more tool homogeneity. Results: A total of 928 screening forms were completed within our 8-week study period; 452 and 443 comparing Tool1 to Tool2 and Tool1 to Tool3, respectively. Thirty-two forms included only Tool1 scores, excluding them from comparative analysis. The average patient age (n=895) was 64.8±21.4 years. Tool1 identified 66.4% of patients at risk, whereas Tool2 and Tool3 identified only 19.2% and 31.4%, respectively. Tool1 and 2 had a PA of 50.2%, whereas Tool1 and Tool3 had a PA of 65.9%. Conclusion: The FRM tool had higher agreement with the validated assessment tool, identifying patients at risk for falling but better identified patients presenting with intoxication, need for procedural sedation and unconsciousness. The other tools generally miss these common ED conditions, putting these patients at risk. Validation and reliability assessments of the FRM tool are warranted.
P132: Developing and piloting a nurse-initiated falls risk screening tool in the emergency department
Authors: Tomlinson R. , Yokota T. , Jaggi P. , Bullard M.
Published: June 2016

Introduction / Innovation Concept: With aging, increasing complexity, and prolonged emergency department (ED) stays, patient falls are an increasing problem. Accreditation Canada recently listed falls risk management (FRM) as a required operational practice (ROP). The University of Alberta ED had no screening tool or education program specific to falls. Gaps in identifying patients with altered consciousness, intoxication, or are undergoing procedural sedation were noted in the Alberta Health Services (AHS) recommended tool. This gap led to the development piloting of an ED specific FRM screening tool. Methods: A literature review was completed to assess current fall assessment tools and their applicability to the ED. No ED specific tools were identified leading to the development of the FRM tool. Prior to the FRM tool being piloted, nursing staff were asked to respond to a voluntary survey on their perceived knowledge of falls management followed by a survey testing their actual knowledge. They were then educated on the FRM and protocol through in-services, power point presentations, and fact sheets. A post education knowledge survey was then sent out. Multidisciplinary working groups provided feedback throughout the pilot, resulting in modifications prior to final implementation. Curriculum, Tool, or Material: The FRM tool consists of 10 variables with a maximum score of 20. Variables included are: falls in the last 12 months? Mechanical (1), Physiological (2), Multiple (3); age ≥70 or frail (2); mobility assist device (1) confusion or disorientation (5); impaired gait (1); incontinence (1); intoxicated (3); procedural sedation (3); and unconscious (5). All except for the last 3 variables were adapted from inpatient risk tools. Patients were categorized as low (1-2 points), moderate (3-4 points), or high risk (5+ points) and those scoring ≥3 had a safety protocol implemented. The survey regarding perceived knowledge for management of falls led to an average score of 86.6% (n=46). When tested on their actual knowledge they scored 48.8% (n=29). Following training on the FRM tool and protocol, the actual knowledge of 18 respondents averaged 83%. Conclusion: The FRM screening tool has been implemented and a comparative study looking at ED risk predictability matched to existing falls risk scores. Based on research findings the FRM will be considered for a provincial implementation.
P133: Characterizing how institutionalized and community-dwelling elderly patients use emergency department services in Regina, Saskatchewan
Authors: Trivedi S. , Roberts C. , Karreman E. , Lyster K.
Published: June 2016

Introduction: In light of recent local initiatives aimed at improving emergency department (ED) patient flow, we sought to characterize how patients aged 65 and older who reside in long term care (LTC) facilities utilize the services of the EDs in Regina, Saskatchewan as compared to an age-matched comparison of community dwelling individuals. Methods: A retrospective chart review was performed with a convenience sample of the first 50 patients who presented to each ED at both hospitals in Regina starting January 1, 2012 for each population. Two separate patient populations were included: those who reside in the health region run LTC facilities and those who live in the community. We abstracted data from a variety of different clinical, demographic and administrative parameters. Results: The charts of 100 patients were reviewed for the LTC population (54 females, mean age 82.6) and 99 patients for the community dwelling population (55 females, mean age 77.3). The CTAS distribution for the LTC patients was found to be CTAS 1: 5%, CTAS 2: 9%, CTAS 3: 43%, CTAS 4: 33% and CTAS 5: 10%. For the community dwelling individuals, the distribution was CTAS 1: 1%, CTAS 2: 21%, CTAS 3: 44%, CTAS 4: 22%, CTAS 5: 10%. This is a significantly different distribution (p = 0.047). From the LTC population, we found that 50% of patients were admitted, with 46% being discharged and 4% leaving without being seen. Furthermore, we also noted that 75% of patients were brought to the ED by EMS. From the community dwelling population, we noted that 43% of patients were admitted, with 55% being discharged and 1% leaving without being seen. This population used EMS services 41% of the time. With respect to length of stay, LTC patients had a mean duration of 5.7 (±4.3 hours) compared to 4.8 (±4.0) hours for the non-LTC population (p=0.111). Conclusion: Our findings suggest that the highest volume of acuity for the LTC patients falls within the CTAS 3 or 4 categories whereas there is a higher proportion of CTAS 2 acuity patients in the community dwelling population. Exactly half of our LTC sample was admitted as compared to 43% of the community population. The LTC population also required EMS services for a considerably higher proportion of their presentations to the ED (75% compared to 41%). It is our intent that the findings of this study will help guide future quality improvement initiatives.
P135: Canadian emergency medicine residents’ training and competency in end-of-life care: a needs assessment
Authors: Turner C.J.
Published: June 2016

Introduction: Emergency Physicians (EPs) face growing numbers of palliative care patients presenting to the emergency department (ED). Formal training for EM residents across Canada in this area is not well described. We sought to describe the training Canadian emergency medicine (EM) residents receive in end of life care issues, their attitudes toward it, self-reported knowledge and skills, and the importance they place on further training in this domain. Methods: We conducted an electronic survey across Canada. We collected demographic data, previous education in palliative care, attitudes toward end of life care, and a self-assessment of competency and desires for further training in the main components of palliative care pertinent to EM. We used simple descriptive statistics, a Mann-Whitney test to assess whether previous formal training in palliative care affected current comfort level, and a combination of self-reported knowledge and importance levels placed on key areas. Results: We received 112 responses from 17 different Universities in Canada, with 42% from the CCFP training stream, and 58% from the FRCP stream. Fifty-four percent of respondents had not completed a palliative care rotation during residency or fellowship, which was overwhelming accounted for by FRCP residents (13%, vs. 82% among CCFPs). Having completed formal training in palliative care was significantly associated with general comfort in managing terminally ill patients (p<0.0001). Sixty percent of subjects felt a lack of knowledge and skills was their main limiting factor in providing ideal care for terminally ill patients in the ED. The skills deemed highest priority with lowest comfort level among residents included discussing withdrawing and withholding care, prognosticating, pharmacology and other symptom control. Preferred methods of receiving palliative care teaching included simulation, bedside teaching and small groups. Conclusion: The care of acute illness among palliative care patients is substantially underrepresented in the Canadian EM curriculum, particularly for FRCP trainees. Formal training is associated with increased comfort in caring for patients at the end of their life. High yield teaching interventions could be directed toward knowledge of withdrawing, prognosticating and symptom control. Simulation, bedside teaching and small groups are the preferred method for receiving such teaching.
P139: Procedural sedation by advanced care paramedics for emergency GI endoscopy
Authors: Wiemer H. , Butler M.B. , Froese P. , Farina D. , Lapierre A. , Carriere C. , Etsell G. , Jones J. , Murray J. , Campbell S.G.
Published: June 2016

Introduction: Acute upper gastrointestinal (UGI) bleeding is a relatively common emergency resulting in death in 6 to 8% of cases. UGI endoscopy is the intervention of choice which requires procedural sedation and analgesia (PSA). The Halifax Infirmary emergency department (ED) performs 1000 PSAs annually, performed by advanced care paramedics (ACPs). This has been shown safe for other indications for PSA, such as orthopedic procedures. Considering that UGI endoscopy involves upper airway manipulation, and patients are at an increased risk of massive bleeding, this procedure would be expected to be more complex and have an increased risk of adverse events (AEs). This study aims to compare PSA for UGI endoscopy performed by ACPs to that for orthopedic procedures for AEs, airway intervention and medication use. Methods: This study is a retrospective review of an ACP-performed ED PSA quality control database. A dataset was built matching 64 UGI endoscopy PSAs to 192 orthopedic PSAs by propensity scores calculated using age, gender and ASA classification. Outcomes assessed were hypotension (SBP < 100, or 15% decrease from baseline), hypoxia (SaO2 < 90), apnea (> 30sec), vomiting, arrhythmias and death in the ED. The need for airway intervention and medication use was assessed. Results: The UGI endoscopy group was 4.60 times more likely to suffer hypotension than the orthopedic group (OR=4.6, CI:2.2-9.6), and a fifth as likely to require airway repositioning (OR=0.2, CI:0.1-0.5). One endoscopy patient required endotracheal intubation. No patient died in either group. Compared to the orthopedic group, the UGI endoscopy group was one-third as likely to receive fentanyl (OR=0.3, CI:0.2-0.6). When fentanyl was administered, endoscopy patients received an average 26.7 mcg less than orthopedic patients. The endoscopy group was 15.4 times more likely to receive ketamine (OR=15.4, CI:4.7-66.5), and received 34.4 mg less on average. Four endoscopy patients received phenylephrine compared to none in the orthopedic group. There were no other differences. Conclusion: ED PSA for UGI endoscopy appears to differ significantly from that performed for orthopedic procedures. It was associated with more frequent hypotension and increased use of ketamine as a sedative. Patients undergoing UGI endoscopy were less likely to receive fentanyl and require airway repositioning. Only patients in the endoscopy group required intubation or a vasopressor agent.
P144: Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies
Authors: Yan J. , Gushulak K. , Columbus M. , Hamelin A. , Stiell I.G.
Published: June 2016

Introduction: Patients with poorly controlled diabetes mellitus (DM) often visit the emergency department (ED) for management of hyperglycemia, diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Many of these patients have a “sentinel” ED visit for other medical conditions prior to their hyperglycemic visit, which may worsen their glucose control. The objective of this study was to describe the epidemiology and outcomes of patients presenting with a sentinel ED visit prior to their visit for a hyperglycemic emergency. Methods: This was a health records review of patients ≥18 years presenting to one of four tertiary care EDs (combined annual census 300,000) with a discharge diagnosis of DM, hyperglycemia, DKA or HHS in a one-year period. Visits for hypoglycemia were excluded. Trained research personnel collected data from medical records including demographics, clinical history and results of investigations. Electronic charts were reviewed to determine if the patient came to the ED within the prior 14 days of their index hyperglycemia visit, and the details and outcomes surrounding both visits. Descriptive statistics were used where appropriate to summarize the data. Results: From January-December 2014, 609 ED visits had a discharge diagnosis of hyperglycemia. Mean (SD) age was 50.4 (19.5) years, and 343 (56.3%) were male. 101/609 visitors (16.6%) had an ED presentation within the previous 14 days from their hyperglycemia visit. 71 (70.3%) of these were discharged from this initial visit and 49/71 (69.0%) were discharged either without their blood glucose checked or with an elevated blood glucose (>11.0 mmol/L). Of the sentinel visits, 58 (57.4%) were for hyperglycemia and 15 (14.9%) were for infection. Upon returning to the ED, 45/101 (44.6%) visitors were subsequently admitted for management of severe hyperglycemia, DKA or HHS. Conclusion: This unique ED-based study demonstrates that patients with DM presenting with hyperglycemia or infection often return and may ultimately require admission. Clinicians should be vigilant in checking blood glucose when these patients present to the ED and provide clear discharge instructions for follow-up and glucose management. Future research should focus on improving glycemic control in these patients in order to prevent further hyperglycemic emergencies from occurring.
P146: Designing better continuing education for rural emergency physicians
Authors: Yeung M.
Published: June 2016

Introduction / Innovation Concept: Rural emergency physicians often work alone, and identify higher needs for continuing professional development in emergency medicine (EM) than urban doctors. We have offered the Community Emergency Medicine Outreach program (CEMO) at 12 rural hospitals in Eastern Ontario since 2009. Each emergency team selects topics in Adult EM for discussion at half-day outreach sessions at their local hospital. Methods: The CEMO program director participated in a Masters of Health Professions Education program. Newly learned concepts were applied to further the development of CEMO. Curriculum, Tool, or Material: Five important lessons learned, and their impacts on CEMO: First, curriculum design is a dynamic process. While CEMO was originally developed for physicians, the program has attracted many participants from other disciplines including nurses, administrators, pharmacists, and learners. Content and delivery have been redesigned to enhance inter-professional learning, which promotes team harmony, local problem solving, and knowledge translation into practice. Second, learning must be highly relevant to the local context to be effective. The content of each CEMO session is tailored to each group’s perceived and ascribed learning needs. CEMO is informed by sociocultural, transformative, experiential and cognitivist learning theories. Teaching strategies include interactive discussion of locally encountered clinical cases, and simulation. Third, it is more effective to integrate new technologies into a larger curriculum than to offer them as stand-alone modules. CEMO incorporates innovative presentation software, screencasts, procedural videos, and online audience response systems to engage participants. Fourth, learning effectiveness is best measured using multiple sources of assessment, and multiple assessments over time. CEMO’s learner assessment strategies include self-reflection at sessions, and months later. Participants consider CEMO’s effects on their practice, including reactions of co-workers and patients to their new skills, knowledge and behaviours. Finally, program evaluation may take many forms, and begins with defining evaluation goals and questions. We have developed a program logic model for CEMO, and a combined process and outcome evaluation is in progress. Conclusion: The application of important educational concepts promotes the design of effective continuing education in emergency medicine for rural health professionals.
LO001: The prevalence of low back pain in the emergency department: a systematic review and primary study in the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia, Canada
Authors: Edwards J. , Hayden J. , Magee K. , Asbridge M.
Published: June 2016

Introduction: Low back pain (LBP) may be having a significant impact on emergency departments (ED) around the world. Two analyses conducted in the USA and Australia suggest that LBP is one of the leading causes of emergency department visits. However, in the peer-reviewed literature, there has been limited focus on the prevalence and management of back pain in the ED setting. Furthermore, the applicability of the available research to our local ED setting is unclear. Methods: This project includes two studies to investigate the prevalence of LBP in the ED: 1. a comprehensive systematic review of the published literature to gather a comprehensive and global perspective about the prevalence of LBP in the ED setting, and 2. a retrospective cross sectional analysis using six years of data from our local ED, the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia. Results: Searches from multiple databases including PubMed (392 citations), resulted in 3024 citations, of which 20 studies were found to have prevalence data for LBP. Studies were reported between 2001–2015 and used mixed methods of data collection, including electronic databases, surveys and patient charts. Ranges for prevalence estimates were 1.9% to 17% of patient visits. Results indicated there are many gaps in the literature, for example research in rural EDs and in Canada. In our primary study, we have identified a sample of 10 000 patients presenting with LBP to our local ED. Analysis of this data will be completed prior to the CAEP conference. Conclusion: This project is the first systematic review; comprehensive search strategy to examine the prevalence of LBP in the ED. It is also the first project to assess the prevalence of LBP in a Canadian ED. Results from this study will inform healthcare providers, as well as administrative and policy decision-makers, of the global and local impact of LBP in the ED, and will identify opportunities for further research to enhance care pathways of patients suffering from LBP.
LO007: A pragmatic randomized and controlled evaluation of nurse-initiated protocols
Authors: Douma M.J. , Dochartiagh D. O , Drake C.A. , Smith K.E.
Published: June 2016

Introduction: Emergency department (ED) overcrowding is a common and complicated challenge for EDs worldwide. Nurse-initiated protocols, diagnostics and/or treatments implemented by nurses prior to patients being seen by a physician or nurse practitioner, have been suggested as a potential strategy to improve patient flow. Methods: This randomized, pragmatic, controlled evaluation of 5 nurse-initiated protocols occured in a crowded inner-city ED. Six physicians and 44 registered nurses, 3 clinical nurse educators and 3 unit managers were involved in revising 5 patient-complaint focused protocols prior to evaluation. Thirty (30/180) emergency nurses were provided 1 hour of training on inclusion and exclusion criteria, procedure and evaluation methods. Data was abstracted in a manner concealing patient allocation. Primary outcomes evaluated included time to diagnostic test, treatment, consultation or ED length of stay. This evaluation was completed following both the CONSORT and SQUIRE guidelines. Results: Time to acetaminophen for the intervention group (n=11) was 1h:04 min on average (95%CI 30min to 1h:37min) whereas the control group (n=9) was 3h:35min (95%CI 2h:21min to 4h:48min). The average length of stay of a suspected fractured-hip in the intervention group (n=5) was 3h:34min (95%CI 1h:49min to 5h:19min) and 7h:34min for the control group (n=4) was (95%CI 5h:26min to 9h:42min). Time to troponin in the intervention group (n=29) was one quarter (average 48min, 95% CI 32min to 64min) of the time it was in the control group (n=14) (average 3h:16min, 95%CI 1h:53min to 4h:39min; p < 0.001). The vaginal bleeding in pregnancy protocol reduced length of stay by roughly fifty-percent; the intervention group (n=11) had a length of stay of 4h:57min (95%CI 3h:46min to 6h:08min) compared to 8h:33min (95% CI 6h:23min to 10h:44min) for the control (n=7) (p < 0.001). There was no statistical difference in the length of stay for patients who received protocolized diagnostics for abdominal pain. Conclusion: Targeting specific patient groups with carefully written protocols can improve the timeliness of care. A cooperative and collaborative interdisciplinary group are essential to success. Having a system in place to ensure ongoing quality in protocol application and interdisciplinary support has proven more difficult than improving the primary outcomes in this evaluation.
LO010: Clinical assessment of transient ischemic attack patients for symptomatic carotid disease in the emergency department
Authors: Motamedi N. , Abdulaziz K. , Sharma M. , Perry J.J.
Published: June 2016

Introduction: TIAs precede about 30% of strokes, with 4-10% having a stroke within 90 days of their TIA. In patients with a TIA due to symptomatic carotid disease, diagnosis and treatment within 2 weeks has been shown to have much better outcomes, while delay beyond 12 weeks no longer reduces subsequent stroke risk. The objective of this study was to determine the clinical findings associated with symptomatic critical disease following an ED visit for TIA to indicate patients requiring prompt carotid imaging. Methods: We performed a prospective Canadian multicenter cohort study, at 13 academic sites, of ED patients with TIA or non-disabling stroke from 2006-2014. Treating ED physicians indicate clinical features on standardized data collection forms. Symptomatic carotid disease was carotid stenosis 50-99%, or carotid dissection, adjudicated by stroke neurology to be the etiology of the index event. Patients were followed by medical review and telephone up to 90 days. Univariate analysis was conducted for clinical features associated with patients who were eventually found to have symptomatic carotid disease as a cause for their TIA. Results: The cohort included 305 patients with and 5,277 without symptomatic carotid disease. Positive predictors of symptomatic carotid disease included older age (74.0 yrs vs 68.0 yrs p<0.0001), male sex (62.9% vs 47.9%; p<0.0001), history of weakness (63.3% vs 41.4%; p<0.0001), language disturbance (52.1% vs 40.0%; p<0.0001), weakness on physical exam (25.5% vs 17.1%; p=0.0002), history of hypertension (74.8% vs 59.5%; p<0.0001), and known history of carotid stenosis (18.9% vs 3.1%; p<0.0001). Negative predictors of symptomatic carotid disease included first ever TIA (56.8% vs 68.8%; p<0.0001), history of altered sensation (39.4% vs 45.8%; p=0.0322), lightheadedness (13.0% vs 22.4%; p=0.0002), and vertigo (3.6% vs 12.7%; p<0.0001). Conclusion: TIA patients with older age, male sex, weakness, language disturbance or history of carotid stenosis need to be promptly imaged to assess for symptomatic carotid disease.
LO016: Can we use administrative data to define an emergency department population at risk for pulmonary embolism? Development and validation of an algorithm to identify a research population
Authors: Burles K. , Wang D. , Grigat D. , Lang E. , Andruchow J. , Innes G. , McRae A.
Published: June 2016

Introduction: Pulmonary embolism (PE) is a potentially life-threatening condition that is in the differential diagnosis of many emergency department (ED) presentations. However, no diagnostic code for suspected PE exists. Thus, identifying the population of patients undergoing PE workup from administrative data for use as a denominator in clinical research and quality improvement can be difficult. To overcome this, we used standardized triage complaint codes and investigations to develop search algorithms useful to identify patients undergoing PE workup from an administrative dataset. Our objective was to quantify the sensitivity, specificity, and case yield of these search algorithms in order to identify a superior search strategy. Methods: Hospital administrative data for adult patients (age ≥18 years), which included standardized triage complaint codes and ICD-10 diagnostic codes for PE, were obtained from four urban EDs between July 2013 to January 2015. Standardized triage complaint codes were evaluated for the proportion of patients diagnosed with PE. Combinations of high-yield presenting complaints, in combination with D-dimer testing or imaging orders, were evaluated for sensitivity, specificity, and predictive values for PE. Results: Of 479,937 patients presenting with 174 different complaints, 1,048 were diagnosed with PE. The best-performing search strategy was the combination of standardized CEDIS complaints of Cardiac Pain, Chest Pain (Cardiac Features), Chest Pain (Non-Cardiac Features), Shortness of Breath, Syncope/Pre-syncope, Hemoptysis, and Unilateral Swollen Limb/Pain, along with with D-dimer testing and/or CTPA, or V/Q scan. This combination captured 808 PE diagnoses for a sensitivity of 77.1% (95%CI 74.4-79.5%) and specificity of 86.8% (95%CI 86.7-86.6%). Conclusion: We identified a high-yield combination of presenting complaints and test ordering that can be used to define an ED population with suspected PE. This population of patients can be used as a denominator in research or quality improvement work that evaluates the utilization of diagnostic testing for PE.
LO020: Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)
Authors: Hawley A. , Hanel E.
Published: June 2016

Introduction: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on first responders, Emergency Medical Services (EMS) and local Emergency Departments. Literature concerning these events is minimal and mostly consists of media reports. Recognizing the lack of epidemiologic data, we sought to accurately determine the patterns and frequency of injuries and illnesses that occur at OCRs, the treatments required, and what proportion require further medical care or transfer to hospital. Methods: Data were extracted from medical charts completed for all patients presenting to the on-site medical team at OCR events across Canada from May to August, 2015. Frequency and patterns of injuries and illnesses were determined as well as treatments and disposition. There were 45 285 OCR participants in 8 events. There were 572 total patient contacts and 557 patients were included in the study. 15 patients were excluded because they were not race participants. Results: Less than 2% of participants at any event required on-site medical care. 11 patients (1.97%) required transfer to hospital by EMS. The majority of injuries were musculoskeletal in nature (74.71%). 495 patients (88.87%) returned to the event with no need for further medical care. The majority of treatments could be provided with first aid training and basic medical equipment. Conclusion: Injury and illness rates at this series of OCRs was similar to other mass gathering events. Injuries were mostly musculoskeletal in nature and required minor treatment. Having a medical team on site likely reduced local hospital and EMS volume from these events. This study raises the question of whether having a physician on site at OCRs could significantly reduce the number of patients advised to seek further medical care or the number of ambulance transfers. Prospective research is needed in order to develop plans for more appropriate resources, safety protocols, and medical staffing, thereby improving patient care and reducing the burden on local EMS and rural hospitals.