bluuebunny/crossref_metadata_2025 huggingface dataset:
P001: Proof-of-principle in a large animal pilot: cardiac arrest may be associated with acute, transient coagulopathy that may drive post-cardiac arrest syndrome
Authors: Yeh C. , Camilotti B. , Hanif H. , Mohindra R. , Sun C. , Kim P. , Lin S. , Sholzberg M.
Published: May 2020

Introduction: Many cardiac arrest survivors die later due to hemorrhage or thromboembolism, thought to be caused by acquired coagulopathy in post-cardiac arrest syndrome (PCAS) from shock and reperfusion injury. Understanding PCAS is a priority identified by the AHA for the prevention of complications in cardiac arrest survivors. Shock dysregulates both coagulation and fibrinolysis. The key effector enzyme thrombin (Th), is responsible for both up- and down-regulating coagulation and fibrinolysis. Measuring early Th activity may allow for predicting PCAS coagulopathy, and early medical intervention in the ED. Therefore, we aimed to characterize the time-course profile of early coagulation using an established pig model of cardiac arrest. Methods: Yorkshire pigs were anaesthetised and intubated, had VF-arrest induced by pacing, and were resuscitated per ACLS. Rotational thromboelastometry (ROTEM) was performed on whole blood at four times: baseline, intra-arrest, post-arrest, and death, using the fibrin-based test with tissue factor to initiate clotting in the presence of a platelet inhibitor cytochalasin D (FIBTEM). Clot time (CT), clot formation time (CFT), alpha-angle during clot formation (Alpha), clot amplitude at 10 min (A10), maximum clot firmness (MCF), and maximum lysis as total percentage (ML%) were quantified. The primary outcome is the overall coagulation initiation measured by CFT, while secondary outcomes include ROTEM parameters reflecting Th activity. Parameters are compared over time in SPSS using repeated measures ANOVA and Bonferroni correction. Results: Pilot data from one experiment show that cardiac arrest causes immediate early changes to coagulation that subsequently normalized with ROSC (Figure 1). CFT was impaired immediately upon cardiac arrest (2.3-fold increase), normalized with ROSC, and impaired again at death when compared with baseline. Consistent with clotting impairment, A10, Alpha, and MCF were all reduced with cardiac arrest, normalized with ROSC, and impaired again at death. Conclusion: Higher initial indices of coagulopathy in patients with cardiac arrest appear to correlate with death and thromboembolism. In this pilot, CFT is acutely modified by cardiac arrest. Since CFT is affected by overall Th activity, early Th dysregulation may be a critical driver of coagulopathy. Th may therefore be a lead target that is modifiable in the emergency post-arrest setting to decrease morbidity and mortality from PCAS in cardiac arrest survivors.
P004: The impact of transfusion guideline on emergency physician transfusion orders
Authors: Williams C. , Campbell S. , Sadek I. , Cheng C. , LeBlanc C.
Published: May 2020

Introduction: Blood transfusions continue to be a critical intervention in patients presenting to emergency departments (ED). Improved understanding of the adverse events associated with transfusions has led to new research to inform and delineate transfusion guidelines. The Nova Scotia Guideline for Blood Component Utilization in Adults and Pediatrics was implemented in June 2017 to reflect current best practice in transfusion medicine. The guideline includes a lowering of the hemoglobin threshold from 80 g/L to 70 g/L for transfusion initiation, to be used in conjunction with the patient's hemodynamic assessment before and after transfusions. Our study aims to augment understanding of transfusion guideline adherence and ED physician transfusing practices at the Halifax Infirmary Emergency Department in Nova Scotia. Methods: A retrospective chart review was conducted on one third of all ED visits involving red-cell transfusions for one year prior to and one year following the guideline implementation. A total of 350 charts were reviewed. The primary data abstracted for the initial transfusion, and subsequent transfusion if applicable, from each reviewed chart included clinical and laboratory data reflective of the transfusion guideline. Based on these data, the transfusion event was classified one of three ways: indicated based on hemoglobin level, indicated based on patient's symptomatic presentation, or unable to determine if transfusion indicated based on charting. Results: The year before guideline implementation, the total number of transfusions initiated at a hemoglobin of between 71-80 was 31 of 146 total transfusions. This number dropped by 23.6% to 22 of 136 in the year following guideline implementation. The number of single-unit transfusions increased by 28.0% from 47 of 146 in the year prior to 56 of 136 in the year after guideline implementation. The initial indication for transfusion being unable to be determined based on charting provided increased by 120%. The indication for subsequent transfusions being unable to be determined based on charting increased by 1500% (P < 0.05). Conclusion: These data suggest that implementing transfusion guidelines effectively reduced the number of transfusions given in the ED setting and increased the number of single-unit transfusions administered. However, the data also suggest the need for better education around transfusion indications and proper documentation clearly outlining the rationale behind the decision to transfuse.
P005: Regional anesthesia in Canadian emergency departments: Emergency physician practices and impressions
Authors: Wiercigroch D. , Friedman S. , Porplycia D. , Ben-Yakov M.
Published: May 2020

Introduction: The use of regional anesthesia (RA) by emergency physicians (EPs) is expanding in frequency and range of application as expertise in point-of-care ultrasound (POCUS) grows, but widespread use remains limited. We sought to characterize the use of RA by Canadian EPs, including practices, perspectives and barriers to use in the ED. Methods: A cross-sectional survey of Canadian EPs was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical responses. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables. Results: The survey was completed by 149/1144 staff EPs, with a response rate of 13%. EPs used RA a median of 2 (IQR 0-4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of EPs, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). EPs agreed that RA is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had POCUS available, however less than half (49.0%) felt comfortable using it for RA. EPs indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use. Conclusion: Canadian EPs engage in limited use of RA but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake of RA in the ED.
P019: What happens to John Doe? Unidentified patients in the emergency department: a retrospective chart review
Authors: Tastad K. , Koh J. , Goodridge D. , Stempien J. , Oyedokun T.
Published: May 2020

Introduction: Patients who are not identified upon presentation to the emergency department (ED), commonly referred to as John or Jane Does (JDs), are a vulnerable population due to the sequelae associated with this lack of patient information. To date, there has been minimal research describing JDs. We aimed to characterize the JD population and determine if it differs significantly from the general ED population. Methods: We conducted a retrospective chart review of 114 JDs admitted to Saskatoon EDs from May 2018 to April 2019. Patients met inclusion criteria if they were provided a unique JD identification number at ED admission because their identities were unknown or unverifiable. Data regarding demographics, clinical presentation, ED course, mode of identification, and major clinical outcomes (i.e. admission rates, mortality rates) were gathered from electronic records. A second reviewer abstracted a random 21.0% sample of charts to ensure validity of the data. The JD population was then compared to the general population of ED patients that presented during the same time period. Results: Male JDs most commonly presented as trauma activations (85.7%) in contrast to female JDs who most commonly presented with issues related to substance abuse (51.4%). Compared to the general ED population, a greater percentage of JDs were categorized as CTAS 1 or 2 (85.8% vs 18.9%, p < 0.0001), more likely to be 44 years of age or younger (82.4% vs 58.5%, p < 0.0001), and more likely to be male (64.9% vs 49.1%, p < 0.0001). Descriptive statistics on the JD population demonstrated that most JDs received consults to inpatient services (58.8%). Of JDs who presented to the ED, 34.2% were admitted to hospital. The mortality of the JD population was 13.2% at 3 months. The ED average (SD) length of stay for JDs was 8.7 (9.0) hours. How JDs were ultimately identified was recorded only 70.2% of the time. Most frequently, JDs identified themselves (26.3%), other identification methods included police services (14.9%), family members (7.9%), registered nurses (6.1%), government-issued identification (5.3%), social work (4.4%) or other measures (5.4%). Conclusion: JD's represent a unique population in the ED. Both their presentations and clinical outcomes differ significantly from the generalized ED population. More research is needed to better identify strategies to improve the management and identification methods of these unique patients.
P022: Use of police and SAR records to identify cases and reduce survivorship bias in prehospital care research
Authors: Stephanian D. , Brubacher J.
Published: May 2020

Introduction: Evidence based medical practices are limited in prehospital care. A 2006 National Academies report on the state of prehospital care indicates that as little as 4% of prehospital care is evidence based. Retrospective case reviews are inexpensive studies that can effectively evaluate current practices and identify opportunities for improvement. Commonly, retrospective reviews in prehospital care rely on electronic health records from hospitals and emergency health services. These data sources suffer from three limitations; survivorship and inclusion biases, a lack of control cases, and difficulty identifying unusual etiologies in databases. Police and search and rescue records are uncommon but promising data sources for certain topics Methods: To test our methodology, we investigated outcomes of suicide attempts by jumping from bridges in Vancouver. We identified patients who threatened, attempted, or jumped from bridges >12m between 2006 and 2017. We describe the population, mortality and adverse outcomes, and identify factors differentiating survivors from fatalities. Police and Coast Guard (CG) records were searched to identify cases. Corresponding records from ambulance, hospitals, and the coroner were identified using date, time, and patient age and sex. Linked records were reviewed and key data extracted. Results: 1208 cases were identified, outcomes were positively identified for 90.3%. 273 were confirmed jumps. 78.2% of ambulance, 90.0% of hospital, and 93.6% of coroner records were identified and linked to corresponding police and CG records. By contrast, an independent search of ambulance records yielded a 99.42% false positive rate, and independent searches of hospital records were not possible due to technological limitations in patient data collection and storage tools. Further, of 197 cases where patients jumped into water, 94 were attended to by EHS, and 52 were transported to hospital. Conclusion: Police and CG records effectively identified patients. Without these data sources, identifying most cases would not have been possible. Since a majority of patients were not transported to EHS or hospital, linking data from these agencies to the hospital and EHS records limited survivorship bias. This methodology may be valuable in future prehospital and ED research, especially for topics with high likelihood of police or SAR contact like suicide attempts or avalanche burials.
P028: Antibiotic prescribing and use of corticosteroids for the emergency department management of acute pharyngitis
Authors: Sheridan C. , Grewal K. , Borgundvaag B. , McLeod S.
Published: May 2020

Introduction: Acute pharyngitis is a common emergency department (ED) presentation. The Centor (Modified/McIsaac) score uses five criteria (age, tonsillar exudates, swollen tender anterior cervical nodes, absence of a cough, and history of fever) to predict Group A Streptococcus (GAS) infection. The recommendation is patients with a Centor score of 0-1 should not undergo testing and should not be given antibiotics, patients with a score of 2-3 may warrant throat cultures, and for patients with a score ≥ 4, empiric antibiotics may be appropriate. Associated pain is often first managed with acetaminophen or non-steroidal anti-inflammatory drugs, however recent evidence suggests a short course of low-to-moderate dose corticosteroids as adjunctive therapy may reduce inflammation and provide pain relief. The objective of this study was to describe the ED management of acute pharyngitis for adult patients presenting to an academic ED over a two-year study period. Methods: This was a retrospective chart review of all adult (> 17 years) patients presenting to Mount Sinai Hospital ED with a discharge diagnosis of acute pharyngitis (ICD-10 code J02.9) from January 1st 2016 to December 31st 2018. Trained research personnel reviewed medical records and extracted data using a computerized, data abstraction form. Results: Of the 638 patients included in the study, 286 (44.8%) had a Centor score of 0-1, 328 (51.4%) had a score of 2-3, and 24 (3.8%) had a score of ≥ 4. Of those with a Centor score of 0-1, 83 (29.0%) had a throat culture, 88 (30.8%) were prescribed antibiotics, 15 (5.2%) were positive for GAS and 74 (25.9%) were given corticosteroids in the ED or at discharge. Of those with a Centor score of 2-3, 156 (47.6%) had a throat culture, 220 (67.1%) were prescribed antibiotics, 44 (13.4%) were positive for GAS, and 145 (44.2%) were given corticosteroids. Of those with a Centor score ≥ 4, 14 (58.3%) had a throat culture, 18 (75.0%) were prescribed antibiotics, 7 (29.2%) were positive for GAS and 12 (50.0%) were given corticosteroids. Conclusion: As predicted, a higher Centor score was associated with higher risk of GAS infection, increased antibiotic prescribing and use of corticosteroids. Many patients with low Centor scores were prescribed antibiotics and also had throat cultures. Further work is required to understand clinical decision making for the management of acute pharyngitis.
P033: Procedural skills training in emergency medicine physicians within the Edmonton zone: a needs assessment
Authors: Schonnop R. , Stauffer B. , Gauri A. , Ha D.
Published: May 2020

Introduction: Procedural skills are a key component of an emergency physician's practice. The Edmonton Zone is a health region that comprises twelve tertiary, urban community and rural community emergency departments (EDs) and represents over three hundred emergency physicians. This study describes the current attitudes toward procedural skill competency, current procedural skill practices, and the role for educational skills training sessions among emergency medicine physicians within a geographical health region. Methods: Multicenter descriptive cross-sectional survey of all emergency medicine physicians working at 12 emergency departments within the Edmonton Zone in 2019 (n = 274). The survey underwent several phases of systematic review; including item generation and reduction, pilot testing, and clinical sensibility testing. Survey items addressed current procedural skill performance frequency, perceived importance and confidence, current methods to maintain competence, barriers and facilitating factors to participation in a curriculum, preferred teaching methods, and desired frequency of practice for each procedural skill. Results: Survey response rate was 53.6%. Variability in frequency of performed procedures was apparent across the type of hospital sites. For majority of skills, there was a significantly positive correlation between the frequency at which a skill was performed and the perceived confidence performing said skill. There was inconsistency and no significant correlation with perceived importance, perceived confidence, or frequency performing a given skill and the desired frequency of training for that skill. Course availability (76.2%) and time (72.8%) are the most common identified barriers to participation in procedural skills training. Conclusion: This study summarized the current emergency department procedural skill practices and attitudes toward procedural skill competency and an educational curriculum among emergency medicine physicians in Edmonton. This represents a step towards targeted continuing professional development in the growing realm of competency-based medical education.
P036: Sensitivity and false negatives in the use of a prehospital sepsis alert
Authors: Sample S. , Quinlan D. , Willis K. , Casement D. , Lutz-Graul K. , Welsford M.
Published: May 2020

Introduction: Prehospital sepsis alerts assist paramedics in identifying patients with sepsis and in communicating this diagnosis to receiving facilities. Following the prospective implementation study of our regional systemic inflammatory response syndrome-based alert criteria (Alert), the purpose of this sub-study was to determine the cause of Alert false negatives (patients without an Alert that subsequently met sepsis criteria in the Emergency Department (ED)). Additionally, the sensitivity of the Alert for detecting sepsis was compared to the Quick Sequential Organ Failure Assessment (qSOFA) and Hamilton Early Warning Score (HEWS). Methods: This study was an additional analysis of the prospective Alert implementation study. Included patients were ≥ 18 years old, transported by a regional Emergency Medical Service and met severe sepsis or septic shock criteria (SS/SS, 2012 Surviving Sepsis Guidelines) in regional EDs in 2013. False negative patients were identified prospectively and reviewed by comparing paramedic determined Alert status to the retrospective application of the Alert criteria to Paramedic Call Report (PCR) data. The Alert sensitivity was first calculated from prospective data, then retrospective sensitivities of the Alert, qSOFA and HEWS were calculated by retrospectively applying these tools to PCRs, using ED diagnosis of SS/SS as reference standard. Results: In 2013, 229 patients met SS/SS criteria in the ED and had PCRs available; 115 (50.2%) were male and median age [interquartile range] was 76.0 [63.0-84.0]. Of 229, 149 (65.0%) arrived in the ED without an Alert (false negatives) and 46 (30.9%) of these met Alert criteria retrospectively and were therefore missed by paramedics. Sensitivity of the Alert was 34.9% when applied by paramedics and 41.5% when applied retrospectively to PCRs. The retrospective sensitivities of the qSOFA and HEWS were 37.6% and 67.7%, respectively. Conclusion: In ED patients diagnosed with SS/SS who arrived with no Alert, the majority (69.1%) were missed by the Alert criteria, rather than by paramedic application of the tool. The Alert had a sensitivity of 34.9%. When applied retrospectively and compared to the Alert, qSOFA had similar sensitivity and HEWS had increased sensitivity. Future research should focus on deriving improved alerts or implementing those with higher accuracy, such as HEWS.
P038: Comparison of diagnostic imaging rates between workplace and non-workplace injuries in the emergency department: a ten-year review
Authors: Sampalli A. , LeBlanc C. , Campbell S. , Vohra M.
Published: May 2020

Background: In Canada, injuries represent 21% of Emergency Department (ED) visits. Faced with occupational injuries, physicians may feel pressured to provide urgent imaging to facilitate expedited return to work. There is not a body of literature to support this practice. Twenty percent of adult ED injuries involve workers compensation. Aim Statement: Tacit pressures were felt to impact imaging rates for patients with workplace injuries, and our aim was to determine if this hypothesis was accurate. We conducted a quality review to assess imaging rates among injuries suffered at work and outside work. A secondary aim was to reduce the harm resulting from non-value-added testing. Measures & Design: Information was collected from the Emergency Department Information System on patients with acute injuries over the age of 16-years including upper limb, lower limb, neck, back and head injuries. Data included both workplace and non-work-related presentations, Canadian Triage and Acuity Scale (CTAS) levels and age at presentation. Imaging included any of X-ray, CT, MRI, or Ultrasound ordered in EDs across the central zone of Nova Scotia from July 1, 2009 to June 30, 2019. A total of 282,860 patient-encounters were included for analysis. Comparison was made between patients presenting under the Workers’ Compensation Board of Nova Scotia (WCB) and those covered by the Department of Health and Wellness (DOHW). Imaging rates for all injuries were also trended over this ten-year period. Evaluation/Results: In patients between 16 and 65-years, the WCB group underwent more imaging (55.3% of visits) than did the DOHW group (43.1% of visits). In the same cohort, there was an overall decrease of over 10% in mean imaging rates for both WBC and DOHW between the first five-year period (2009-2013) and the second five-year study period (2013-2018). Imaging rates for WCB and DOHW converged with each decade beyond 35 years of age. No comparison was possible beyond 85-years, due to the absence of WCB presentations. Discussion/Impact: Patients presenting to the ED with workplace injuries are imaged at a higher rate than those covered by the DOHW. Campaigns promoting value-added care may have impacted imaging rates during the ten-year study period, explaining the decline in ED imaging for all injuries. While this 10% decrease in overall imaging is encouraging, these preliminary data indicate the need for further education on resource stewardship, especially for patients presenting to the ED with workplace injuries.
P049: Goals of care discussion in the emergency department: is it possible
Authors: Péloquin F. , Marmen É. , Gélinas V. , Plaisance A. , Archambault P.
Published: May 2020

Introduction: The Institut national d'excellence en santé et en services sociaux in Quebec published guidelines suggesting that emergency physicians should establish emergency department (ED) patients’ goals of care when appropriate. The objective of this study was to explore emergency physicians’ opinions about leading goals of care discussion (GCD) in their daily practice. Methods: This study used a qualitative design based on the Normalisation Process Theory (NPT); a middle-range theory used to explain the sustainability of implementing complex healthcare interventions. It was conducted in a single academic ED in Lévis, Québec. We planned to recruit a minimal convenience sample of 10 participants. Between April and May 2018, we conducted semi-structured interviews and transcribed the audio records verbatims. Deductive thematic analysis based on the NPT was conducted using Nvivo 12.0. Two authors codified the content of each interview under the four NPT macro-level constructs: coherence, cognitive participation, collective action and reflexive monitoring. A kappa score was calculated to measure the coding inter-rater reliability. Results: We interviewed 10 ED physicians (50 % women; 60% certified by the College of Family Physicians of Canada (Emergency Medicine)). No new ideas emerged after the 9th interview. Our thematic analysis identified 13 themes. Inter-rater reliability of coding was substantial (kappa = 0.72). The coherence construct contained the following themes: common concept of interpersonal communication, efficiency of care and anxiety generated by the discussion, the identification of an acute deterioration leading to the GCD, coming together of clinician, patient and family, and the importance of knowing patients’ goals of care before medical handover. The cognitive participation construct involved the following themes: lack of training on the new goals of care form and availability of reminders to promote the recommendation. One theme characterized the collective action construct: heterogeneous prioritization for leading GCD. The reflexive monitoring construct contained 4 themes: need to take action before patients consult in the ED, need to develop education programs, need for legislation and the impossibility of systematic GCD for all patients. Conclusion: Goals of care discussion is possible and essential with selected patients in the ED. Nevertheless, policy-making efforts remain necessary to ensure the systematization of the recommendation.
P054: Delay in decision to transfer time for critically ill patients transported by air ambulance in Ontario
Authors: Myers V. , Nolan B.
Published: May 2020

Introduction: Delays in definitive management of critically ill patients are known to drive poor clinical outcomes. A scarcely studied time period in interfacility transfer is the time between initial patient presentation and the decision to transfer. This study seeks to identify patient, environmental and institutional characteristics associated with delays in decision to transfer critically ill patients by air ambulance to a tertiary care centre. Methods: Patients >18 years old who underwent emergent air ambulance interfacility transport to a tertiary care centre were included. Patient records were located in a provincial air ambulance database. The primary exposure variable was time from patient presentation to initial call to facilitate transfer. Patient, environmental and institutional characteristics were identified using stepwise variable selection at a significance of 0.1. These characteristics were then explored using quantile regression to identify significant factors associated with delay in transport initiation. Results: A total of 11231 patients were included in the analysis. There were 5009 females (44.60%) and 6222 males (55.4%). The median age of patients was 57. The median time to initiate the transfer was 3.05 hours. The variables identified with stepwise selection were gender, category of illness, heart rate, systolic blood pressure, Glasgow coma scale, vasopressor usage, blood product usage, time of day, and type of sending site. The following factors were significantly (p < 0.05) associated with an increase in time to initiate transfer compared to the reference category at the 90th centile of time: cardiac illness (+1.45h), gastrointestinal illness (+3.27h), respiratory illness (+4.90h), sepsis (+3.03h), vasopressors (+2.31h), and an evening hour of transport (+3.67h). The following factors were significantly (p < 0.05) associated with a decrease in time to initiate transfer compared to the reference category at the 90th centile of time: neurologic illness (-1.45h), obstetrical illness (-1.56h), trauma (-3.14h), GCS <8 (-0.98h), blood transfusion (-1.47h), and sending site being a community hospital >100 beds (-2.26h), <100 beds (-4.71h), or nursing station (-10.02h). Conclusion: Time to initiate transfer represents a significant window in a patient's transport journey. In looking at the predictors of early or late initiation of transfers, these findings provide education and quality improvement opportunities in decreasing time to definitive care in critically ill populations.
P057: Impact of a clinical pathway for the treatment of acute asthma in the emergency department
Authors: Messier F. , Deshaies J. , Breault G.
Published: May 2020

Introduction: In Canada, acute asthma is a common cause of emergency department (ED) attendance and its treatment is affected by ED overcrowding and increasing wait times. Literature suggests that a clinical pathway (CP) for the treatment of acute asthma can increase the use of medical therapy, reduce hospital admission rates and decrease associated costs. However, only few have looked at the effect on ED length of stay (ED LOS) when such a CP is initiated by triage nurse/respiratory therapist among adults. In this optic, an asthma CP was launched on Feb. 2016 at Centre Hospitalier Universitaire de Sherbrooke (QC) and included medical directives allowing triage nurse and respiratory therapist initiation of treatment. Methods: The objectives are to determine the effect of an ED nurse/respiratory therapist-initiated asthma CP on (1) ED LOS, (2) time-to-treatment (beta-agonist, corticosteroids), time-to-MD and other secondary outcomes. This was a retrospective before-after study. Adults presenting to the ED before and after CP implementation with a final diagnosis of asthma or asthma exacerbation were eligible. The groups A (before implementation) and B (after implementation) were compared for ED LOS. Three subgroups of 50 patients were generated and compared for outcomes: A1 (before implementation), B1 (after implementation without CP) and B2 (after implementation with CP). All five groups were controlled for triage level and sex. Results: In total, 1086 patients were included; 543 before implementation (Mar. 2011 – Feb. 2016) and 543 after (Feb. 2016 – Jun. 2019), of whom 14% (N = 77) were treated by CP. The average ED LOS was similar (10.36h vs 10.65h; (p = 0,31)) in group A and in group B. In groups A1, B1 and B2, the median ED LOS were respectively 6.00, 6.84, 4.80; these differences were not statistically significant. The average time-to-treatment for beta-agonist in A1, B1 and B2 was respectively 148, 180 and 50 mins; the differences between B2 and A1 and between B2 and B1 were both statistically significant (p < 0,05). Conclusion: Although this study indicates a low compliance to the CP, it shows that time-to-treatment can be reduced. It didn't demonstrate any statistically significant decrease in ED LOS, most likely due to low number of patients and non-normal distribution, but the 1.2h shorter could be a major advantage if it proves true. Further studies are essential to understand facilitators and alleviate the barriers in anticipation of a multi-centric implementation.
P059: Characteristics of older adults attending the emergency department for suicidal thoughts or voluntary intoxication: a multicenter retrospective cohort study
Authors: Mercier E. , Boulet S. , Gagnon A. , Nadeau A. , Mowbray F.
Published: May 2020

Introduction: Suicidal thoughts and self-harm are disproportionately prevalent among older adults but are frequently overlooked by emergency physicians. Objective: This study aims to explore the characteristics of older adults visiting the ED for suicidal thoughts or voluntary intoxications. Methods: All older adults (□ 65 years old) who visited one of the five CHU de Quebec’ EDs in 2016 were eligible. The medical charts of patients who reported suicidal thoughts or intoxication in triage or received a relevant discharge diagnosis were reviewed. Involuntary intoxications were excluded. Descriptive statistics were used to present the results. Results: Results: A total of 478 ED visits were identified, of which 332 ED visits (n= 279 patients) were included. The mean age of the ED cohort was 72.6 (standard deviation 6.8) years old and 41.6% were female. Mood disorders (41.2%) and alcoholism (40.5%) were common. Most included patients had a diagnosis of voluntary intoxication (73.2%), including two suicides (0.6%). Following 109 ED visits (30.0%), patients were referred for a mental health assessment. Half of all ED visits resulted in a discharge by the emergency physician (50.0%), while 27.4% were admitted for in-patient care. In the subsequent year (2017), 38.4% returned to the ED for suicidal ideations or self-harm of which 7.9% attended the ED □ 5 times. Conclusion: ED visits for suicidal thoughts and voluntary intoxication in older adults are more common among men with known mood disorders or alcoholism. Referral for a mental health assessment is inconsistent. ED-initiated interventions designed for this population are needed.
P060: Bridging the gap: Using a tele-resuscitation network to improve pediatric outcomes in a community hospital setting
Authors: Mateus L. , Bilic M. , Roy M. , Setrak R. , Sulowski C. , Stefanowska P. , Law M.
Published: May 2020

Background: Telemedicine has been defined as the use of technology to provide healthcare when the provider and patient are geographically separated. Use of telemedicine to meet the needs of specific populations has become increasingly common across Canada. The current study employs the Ontario Telemedicine Network (OTN) to connect the emergency departments of a community hospital system and a pediatric tertiary care hospital. OTN functions through a two-way video conferencing system, allowing physicians at the tertiary site to see and hear the patient being treated in the community hospitals. Aim Statement: The aim of this project is to ensure essential care is provided to CTAS 1 and 2 pediatric patients who present to Niagara Health emergency departments, to increase the number of appropriate patient transfers. Measures & Design: Data for this project include a) description of common diagnoses, b) time of call, c) occurrence of transfers, and d) professional perceptions of the technology. A descriptive design was used together with the implementation of quality improvement cycles as the intervention occurred. Quality improvement methodologies including plan-do-study-act (PDSA) cycles ensured continuous improvement to the process of OTN use and therefore patient safety throughout the study. Evaluation/Results: Since the intervention was employed on December 17, 2018 there have been a total of 19 cases for which 4 transfers were requested. Changes to the process were made including the addition of weekly technology tests and feedback to health professionals involved to garner further support for the use. Results have indicated that seizure was the most common diagnosis, accounting for 37% of cases. The majority of calls were placed after 19:00 hours with no calls being placed between 24:00 and 10:00. Discussion/Impact: Healthcare providers had positive perceptions of the technology agreeing that decision making between on-site and remote teams was timely and collaborative, as well as that patient care and outcomes were improved with its use. The results of this study will be used to determine the benefits of employing telemedicine in the emergency departments of other hospital systems.
P069: Implementing supervised consumption service access for emergency department patients
Authors: Lam N. , Rosenblum R. , Kaban T. , Dmitrienko K. , Oczkowski D. , Dong K.
Published: May 2020

Background: Unintentional opioid overdoses in and around acute care hospitals, including in the ED, are of increasing concern. In April 2018, the Addiction Recovery and Community Health (ARCH) Team at the Royal Alexandra Hospital opened the first acute care Supervised Consumption Service (SCS) in North America available to inpatients. In the SCS, patients can consume substances by injection, oral or intranasal routes under nursing supervision; immediate assistance is provided if an overdose occurs. After a quality assurance review, work began to expand SCS access to ED patients as well. Aim Statement: By expanding SCS access to ED patients, we aim to reduce unintentional and unwitnessed opioid overdoses in registered ED patients to 0 per month by the end of 2020. Measures & Design: Between June 13-July 15, 2019, ARCH ED Registered Nurses were asked to identify ED patients with a history of active substance use who may potentially require SCS access. Nurses identified 69 patients over 43 8-hour shifts (range 0-4 patients per shift); thus, we anticipated an average of 5 ED patients per 24-hour period to potentially require SCS access. Based on this evidence of need, ARCH leadership worked with a) hospital legal team and Health Canada to expand SCS access to ED patients; b) ED leadership to develop a procedure and flowchart for ED SCS access. ED patients were able to access the SCS effective October 1, 2019. Evaluation/Results: From October 1 to December 1, 2019, the SCS had 35 visits by 23 unique ED patients. The median time spent in the SCS was 42.5 minutes (range 14.0-140.0 minutes). Methamphetamine was the most commonly used substance (19, 45.2%), followed by fentanyl (10, 23.8%); substances were all injected (91.4% into a vein and 8.6% into an existing IV). In this time period, there were zero unintentional, unwitnessed opioid poisonings in registered ED patients. Data collection is ongoing and will expand to include chief complaint, ED length of stay and discharge status. Discussion/Impact: Being able to reduce unintentional overdoses and unwitnessed injection drug use in the ED has the potential to improve both patient and staff safety. Next steps include a case series designed to examine the impact of SCS access on emergency care, retention in treatment and uptake into addiction treatment.
P071: Artificial intelligence in emergency medicine: A scoping review
Authors: Kirubarajan A. , Taher A. , Khan S. , Masood S.
Published: May 2020

Introduction: The study of artificial intelligence (AI) in medicine has become increasingly popular over the last decade. The emergency department (ED) is uniquely situated to benefit from AI due to its power of diagnostic prediction, and its ability to continuously improve with time. However, there is a lack of understanding of the breadth and scope of AI applications in emergency medicine, and evidence supporting its use. Methods: Our scoping review was completed according to PRISMA-ScR guidelines and was published a priori on Open Science Forum. We systematically searched databases (Medline-OVID, EMBASE, CINAHL, and IEEE) for AI interventions relevant to the ED. Study selection and data extraction was performed independently by two investigators. We categorized studies based on type of AI model used, location of intervention, clinical focus, intervention sub-type, and type of comparator. Results: Of the 1483 original database citations, a total of 181 studies were included in the scoping review. Inter-rater reliability for study screening for titles and abstracts was 89.1%, and for full-text review was 77.8%. Overall, we found that 44 (24.3%) studies utilized supervised learning, 63 (34.8%) studies evaluated unsupervised learning, and 13 (7.2%) studies utilized natural language processing. 17 (9.4%) studies were conducted in the pre-hospital environment, with the remainder occurring either in the ED or the trauma bay. The majority of interventions centered around prediction (n = 73, 40.3%). 48 studies (25.5%) analyzed AI interventions for diagnosis. 23 (12.7%) interventions focused on diagnostic imaging. 89 (49.2%) studies did not have a comparator to their AI intervention. 63 (34.8%) studies used statistical models as a comparator, 19 (10.5%) of which were clinical decision making tools. 15 (8.3%) studies used humans as comparators, with 12 of the 15 (80%) studies showing superiority in favour of the AI intervention when compared to a human. Conclusion: AI-related research is rapidly increasing in emergency medicine. AI interventions are heterogeneous in both purpose and design, but primarily focus on predictive modeling. Most studies do not involve a human comparator and lack information on patient-oriented outcomes. While some studies show promising results for AI-based interventions, there remains uncertainty regarding their superiority over standard practice, and further research is needed prior to clinical implementation.
P073: Emergency department trauma team in situ simulations at an urban, academic centre to improve team communication and detect latent safety threats
Authors: Kester-Greene N. , Notario L. , Heipel H. , DaLuz L. , Nathens A. , DeSousa S. , Ryzynski A.
Published: May 2020

Innovation Concept: Effective communication for ad hoc teams is critical to successful management of multisystem trauma patients, to improve situational awareness and to mitigate risk of error. OBJECTIVES 1. Improve communication of ad hoc teams. 2. Identify system gaps. INNOVATION Team in situ simulations provide a unique opportunity to practice communication and assess systems in the real environment. Our trauma team consists of residents and staff from emergency services, general surgery, orthopedics, anaesthesia, nursing and respiratory therapy. Methods: A team of subject matter experts (SME's) from trauma, nursing, emergency medicine and simulation co-developed curriculum in response to a needs assessment that identified gaps in systems and team communication. The simulation occurred in the actual trauma bay. The on-call trauma team was paged and expected to manage a simulated multisystem trauma patient. Once the team arrived, they participated in a briefing, manikin-based simulation and a communication and system focused debriefing. Curriculum, Tool, or Material: Monthly scenarios consisted of management of a blunt trauma patient, emergency airway and massive hemorrhage protocol. Teams were assessed on communication skills and timeliness of interventions. Debriefing consisted of identification of system gaps and latent safety threats. Feedback was given by each discipline followed by SME's. Information was gathered from participant evaluations (5-point Likert scale and open ended questions) and group debrief. Feedback was themed and actions taken to co-create interventions to communication gaps and latent safety threats. As a result, cricothyroidotomy trays were standardized throughout the hospital to mitigate confusion, time delay and unfamiliarity during difficult airway interventions. Participants felt the exercise was an effective means of practicing interprofessional communication and role clarity, and improved their attitude towards the same. Conclusion: In situ simulation-based education with ad hoc trauma teams can improve interprofessional communication and identify latent safety threats for the management of multisystem trauma patients.
P074: Emergency department utilization and outcomes for patients with early pregnancy complications
Authors: Glicksman R. , Little D. , Thompson C. , McLeod S. , Varner C.
Published: May 2020

Introduction: Affecting roughly 1 in 5 pregnancies, early pregnancy loss is a common experience for reproductive-aged women. In Canada, most women do not establish care with an obstetrical provider until the second trimester of pregnancy. Consequently, pregnant patients experiencing symptoms of early pregnancy loss frequently access care in the emergency department (ED). The objective of this study was to describe the resource utilization and outcomes of women presenting to two Ontario EDs for early pregnancy loss or threatened early pregnancy loss. Methods: This was a retrospective cohort study of pregnant (≤20 weeks), adult (≥18 years) women in two EDs (one community hospital with 110,000 annual ED visits; one academic hospital with 65,000 annual ED visits) between January 2010 and December 2017. Patients were identified by diagnostic codes indicating early pregnancy loss or threatened early pregnancy loss. Results: A total of 16,091 patients were included, with a mean (SD) age of 32.8 (5.6) years. Patients had a total of 22,410 ED visits for early pregnancy complications, accounting for 1.6% of the EDs’ combined visits during the study period. Threatened abortion (n = 11,265, 50.3%) was the most common ED diagnosis, followed by spontaneous abortion (n = 5,652, 25.2%), ectopic pregnancy (n = 3,242, 14.5%), missed abortion (n = 1,541, 6.9%), and other diagnoses (n = 710, 3.2%). 8,000 (44.8%) patients had a radiologist-interpreted ultrasound performed during the initial ED visit. Median (IQR) ED length of stay was 3.4 (2.3 to 5.1) hours. There were 4,561 (25.6%) return ED visits within 30 days, of which 2,317 (50.8%) occurred less than 24 hours of index visit, and 481 (10.6%) were for scheduled, next day ultrasound. The total number of hospital admissions was 1,793 (8.0%), and the majority were for ectopic pregnancy (n = 1,052, 58.7%). Of admitted patients, 1,320 (73.6%) underwent surgical interventions related to early pregnancy. There were 474 (10.4%) patients admitted to hospital during return ED visits. Conclusion: Pregnant patients experiencing symptoms of early pregnancy loss in the ED frequently had radiologist-interpreted US and low rates of hospital admission, yet had high rates of return ED visits. This study highlights the heavy reliance on Ontario EDs to care for patients experiencing complications of early pregnancy.
P078: Impact of vaping on lung health and visits to the emergency department: a cross-sectional study
Authors: Junqueira D. , Zhou K. , Couperthwaite S. , Meyer J. , Rowe B.
Published: May 2020

Introduction: Despite being legal in Canada, the vaporized liquid of vaping systems contains several chemicals presenting unknown risks to lung health and little is known about their use in patients visiting the emergency department (ED). This study explores associations between exposure to inhaled products and respiratory presentations in the ED. Methods: A cross-sectional lung health survey among patients presenting to a Canadian ED was conducted, exploring the association between inhaled toxic exposures (e.g., vaping, cannabis and cigarette smoking) and visits related to respiratory symptoms. Eligible participants were ambulatory (CTAS 2 to 5), stable, adults (≥ 17 years) visiting the ED from July to November, 2019. Results are described as frequencies and percentages (categorical variables) and medians with interquartile range (IQR, continuous variables). Univariate and multivariate logistic regression models report associations as odds ratios (OR) with 95% confidence intervals (CIs). The Health Research Ethics Board approved the study. Results: From 1433 eligible patients, 1024 (71%) completed the survey. The median age was 43.5 (IQR: 29, 60), and 51% were female. Overall, 177 (17%) reported ≥1 respiratory symptoms and 83 (8%) reported using any vaping products. In a univariate regression analysis, exposure to vaping was positively associated with ED visits related to respiratory symptoms (OR 2.11, 95% CI: 1.26 to 3.54). In the multivariate model, vaping and a previous diagnosis of ≥1 respiratory conditions showed positive association with respiratory-related ED visits (OR 1.86, 95% CI: 1.03 to 3.33; and OR 2.13, 95% CI: 1.50 to 3.02, respectively). There was evidence of an additive effect of the combined exposure to cigarettes and vaping and respiratory-related ED visits (OR 3.22, 95% CI: 1.61 to 6.43). Smoking cannabis and cigarettes alone were not associated with increased risk of respiratory-related visits. Conclusion: Using vaping products increased the occurrence of respiratory-related ED visits, particularly in people with pre-existing lung conditions. A dose-response relationship exists where the risk is highest in patients inhaling a combination of toxins. Contrary to previous assumptions, the use of vaping products has a negative impact on lung health.