bluuebunny/crossref_metadata_2025 huggingface dataset:
P117: A pilot program of physician at triage conducted at a tertiary care hospital improved measures of emergency department throughput and provides a potential solution for emergency department overcrowding
Authors: Powell J. D. , Hughes A. , Scott R. , Balfour N. , McInnes G. , Karogiannis D. , Hebert J. , Cabral J. , Fasick D. , Harris D. , Ertel M.
Published: May 2018

Introduction: Emergency Department Overcrowding (EDOC) is a multifactorial issue that leads to Access Block for patients needing emergency care. Identified as a national problem, patients presenting to a Canadian Emergency Department (ED) at a time of overcrowding have higher rates of admission to hospital and increased seven-day mortality. Using the well accepted input-throughput-output model to study EDOC, current research has focused on throughput as a measure of patient flow, reported as ED length of stay (LOS). In fact, ED LOS and ED beds occupied by inpatients are two “extremely important indicators of EDOC identified by a 2005 survey of Canadian ED directors. One proposed solution to improve ED throughput is to utilize a physician at triage (PAT) to rapidly assess newly arriving patients. In 2017, a pilot PAT program was trialed at Kelowna General Hospital (KGH), a tertiary care hospital, as part of a PDSA cycle. The aim was to mitigate EDOC by improving ED throughput by the end of 2018, to meet the national targets for ED LOS suggested in the 2013 CAEP position statement. Methods: During the fiscal periods 1-6 (April 1 to September 7, 2017) a PAT shift occurred daily from 1000-2200, over four long weekends. ED LOS, time to inpatient bed, time to physician initial assessment (PIA), number of British Columbia Ambulance Service (BCAS) offload delays, and number of patients who left without being seen (LWBS) were extracted from an administrative database. Results were retrospectively analyzed and compared to data from 1000-2200 of non-PAT trial days during the trial periods. Results: Median ED LOS decreased from 3.8 to 3.4 hours for high-acuity patients (CTAS 1-3), from 2.1 to 1.8 hours for low-acuity patients (CTAS 4-5), and from 9.3 to 8.0 hours for all admitted patients. During PAT trial weekends, there was a decrease in the average time to PIA by 65% (from 73 to 26 minutes for CTAS 2-5), average number of daily BCAS offload delays by 39% (from 2.3 to 1.4 delays per day), and number of patients who LWBS from 2.4% to 1.7%. Conclusion: The implementation of PAT was associated with improvements in all five measures of ED throughput, providing a potential solution for EDOC at KGH. ED LOS was reduced compared to non-PAT control days, successfully meeting the suggested national targets. PAT could improve efficiency, resulting in the ability to see more patients in the ED, and increase the quality and safety of ED practice. Next, we hope to prospectively evaluate PAT, continuing to analyze these process measures, perform a cost-benefit analysis, and formally assess ED staff and patient perceptions of the program.
P119: Pain free laceration repairs using intra-nasal ketamine: DosINK 1- A dose escalation clinical trial
Authors: Rached-dastous S. , Bailey B. , Marquis C. , Desjardins M. , Lebel D. , Trottier E. D.
Published: May 2018

Introduction: Laceration is common in children presenting to the emergency department (ED). They are often uncooperative related to pain and distressed during repair. Currently, there are wide variations regarding sedation and analgesia practices when sutures are required. There is a growing interest in the intranasal (IN) route for procedural sedation and pain control because of its effectiveness potential and ease of administration. Few studies have evaluated IN ketamine for procedural sedation in children with reported doses ranging from 3 to 9 mg/kg. The objective is to evaluate the optimal IN ketamine dose for effective and safe procedural sedation for laceration repair in children aged 1 to 12 years. Methods: A dose escalation clinical trial with an initial dose of 3 mg/kg of IN ketamine up to a maximum dose of 9 mg/kg in children 1 to 12 years old, using a 3+3 trial design. For each tested dose, 3 patients are enrolled. Escalation to the next dose is permitted if sedation is unsuccessful in at least one patient without serious adverse event (SAE). Regression to prior dose is warranted in the occurrence of two or more SEAs. This process is repeated until effective sedation for 6 patients at two consecutive doses is achieved with a maximum of 1 SAE or if regression occurs. The primary outcome is the optimal dose for successful procedural sedation as per the PERC/PECARN consensus criteria. Secondary outcome, namely, pain and anxiety levels, parent, patient and provider satisfaction, recovery time, length of stay in the ED, side effects and adverse event are recorded. Results: Nine patients have been recruited from March to December 2017 with median age of 2.9 years-old and with laceration length of 2 to 5 cm and with facial involvement in 55% of cases, respectively. Sedation was successful in 1/3, 1/3 and 3/3 of patients at doses of 3, 4, 5 mg/kg respectively, without any SAE. Median time from ketamine administration to return to baseline status and discharge were 35 and 98 min, respectively. We expect to complete patient recruitment in March 2018. Conclusion: The results from our trial is a groundwork for future dose-finding study. Pending study completion, a multicentric dose validation trial, is set up to further validate the optimal dose from dosINK1 trial. IN ketamine has the potential to improve the field of procedural sedation for children by introducing an effective IN agent with respiratory stability but without the need for an IV line insertion not otherwise needed.
P126: Development of inclusion and exclusion criteria for ECPR in a regional hospital
Authors: Rollo D. , Atkinson P. , Fraser J. , Mekwan J. , French J. P. , Lutchmedial S.
Published: May 2018

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.
P129: Variability in ordering of computed tomography (CT) scans among emergency physicians
Authors: Salehi L. , Phalpher P. , Valani R. , Hou Y. , Mercuri M.
Published: May 2018

Introduction: The increased availability and increased utilization of Computed Tomography (CT) imaging as a diagnostic tool has in the past several years led to concerns regarding the unknown and potentially harmful effects of ionizing radiation exposure to patients, as well as the increased cost to the health care system. Multiple education campaigns (e.g. Choosing Wisely) and institution-wide interventions have been implemented in order to limit the use of potentially unnecessary CT imaging. Two specific modalities CT head and CT angiography to rule out pulmonary embolism (CT PE) have been identified as potential targets of these interventions due to their likely overutilization in the clinical ED setting. The objective of this study was to determine the interphysician variability in the ordering rates of CT head and CT PE, and to determine if any correlation existed between CT head and CT PE ordering rates among physicians. Methods: Data was collected on all diagnostic imaging ordered by ED physicians at two very high volume community hospitals during the 4-year period between 2013 and 2016. Analysis was limited to those physicians who worked at least 3 of the 4 years at either site and saw at least 1000 patients per year. The ordering rates for each physician were calculated by dividing the number of the imaging modality ordered over the total number of patients seen. Correlation coefficients (r values) were calculated to determine if a linear correlation existed between increased CT head and increased CT PE ordering rates. Results: The DI ordering data for a total of 44 ED physicians were analyzed. Results show average 4-year ordering rates for CT heads among ED physicians ranging from 4.0% to 13.9%, and CT PE ordering rates ranging from 0.1% - 1.7%. The correlation coefficient between CT head and CT PE ordering rates was positive for all 4 years, with a statistically significant (p<0.05) correlation coefficient of 0.53. Conclusion: There is a wide degree of variability in DI ordering patterns among physicians working within the same clinical environment. Further exploration of this interphysician variability will be helpful in designing strategies to mitigate overutilization of diagnostic imaging.
P136: Evaluating the use of the YEARS clinical decision rule for diagnosing pulmonary embolism in the Emergency Department
Authors: Sharif S. , Kearon C. , Eventov M. , Li M. , Jiang R. , Sneath P. , Leung R. , de Wit K.
Published: May 2018

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 and those without a D-dimer test were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.
P137: Automation of follow-up microbiology culture results in patients discharged from the emergency department
Authors: Shelton D. M. , Hefferon D. , Sinclair P. , Janicijevic Z.
Published: May 2018

Introduction: At Sunnybrook Health Sciences Centres Emergency Department (ED), delays occurred in reporting positive microbiology culture results of patients discharged from the ED. Follow-up of culture results was driven by a manual paper based process that was inefficient and resulted in a one to three day delay in reporting results. The previous system was time consuming, labour intensive and prone to human error. Timely reporting of microbiology culture results is important to ensuring that patients receive optimal care. The aim is that >80% of positive microbiology culture results of patients discharged from Sunnybrook Health Sciences Centre ED will be followed-up within 24 hours of results being available from the lab. Methods: Outcome Measure Percentage of positive culture results followed up within 24 hours Process Measure Time from availability of culture results from lab to completion of patient follow-up Balancing Measure Number of positive culture results not displayed in ED server Change Idea Electronically push positive culture results to an ED server that is periodically checked daily and acted upon. An electronic interface was created to capture positive results from the microbiology lab in real time. Results: There was a 45 hour reduction in the mean time to complete a patients follow-up of culture results (59 hours pre vs. 14 hours post, p=0.03). We surpassed our aim of >80% follow-up within 24 hours. Conclusion: A significant reduction to completing a patients follow-up of microbiology culture results was achieved by automating the availability of results and eliminating the manual process previously used in relaying results from the microbiology lab to ED. This new process has the following benefits: 1) Improves timely reporting of culture results to patients, that may require initiation or change in antibiotics 2) Enhanced patient safety due to elimination of human error 3) Decreased workload due to elimination of batching of results and data entry 4) Entire process is streamlined, since only positive culture results are transmitted for follow-up.
P141: Predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool
Authors: Sinclair J. E. , Duncan S. , Price P. , Thomas L. , Willmore A. , Dionne R. , Austin M.
Published: May 2018

Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &/or history of fever and 2 or more signs of hypoperfusion (eg. SBP<90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index >1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.
P143: An exploratory study to understand relationship between gameplay experience and observed actions
Authors: Singh C. B. , Huang S. Y. , Jeong E. , Dang R. , Chan T. M.
Published: May 2018

Introduction: The GridlockED game is a serious game aimed at teaching junior learners about flow and organization in the emergency department(ED). With serious games, the mechanism of learning is thought to be via the gameplay experience. Objectives built into gameplay are aimed at teaching players about a specific concept; in this case, we hoped to teach players about interprofessional collaboration and basic mechanics that drive flow in the ED. However, before a player can be taught, he or she must be engaged and have a positive gameplay experience. From the GridlockED gameplay, we aim to explore how a players gameplay experience related to observed actions while playing the game, including participating in decision making and keeping the team organized. Methods: From April-August 2017, participants were invited to play 4 turns of a GridlockED game session. They were video recorded during gameplay. After playing the game, they were surveyed using the previously derived Game Experience Questionnaire (GEQ) to measure their gameplay experience. The videos were reviewed by two research team members (SH, EJ), tallying various observed game actions. We conducted Pearson correlation between players GEQ total score and their observed actions. Results: A total of 32 participants (13 attendings, 5 senior residents, 10 junior residents, and 4 nurses) played the game. The average total GEQ was 67.2/132 (SD=10.7), suggesting most players had a moderately good gameplay experience. The total GEQ score correlated with component subscores within the questionnaire. Overall observed activity correlated well with each observed action subtype. However, the GEQ total score did not correlate significantly with the total observed action (Pearsons r=0.18,p=0.32). GEQ total score was found to be moderately correlated to an observation that a player participated in determining strategy during gameplay (r=0.36,p=0.04). There was a moderate negative correlation between determining strategy during gameplay and teaching about the game (r=-0.37,p=0.04) or emergency medicine concepts (r=-0.47,p<0.01). Conclusion: The GEQ is internally consistent, but does not have a strong relationship to observed actions, suggesting that game experience does not necessarily correlate with observable actions. This suggests that players may be intellectually stimulated or engaged without necessarily completing any observable actions during gameplay.
P144: Assessment of the quality of evidence presented at the Canadian Association of Emergency Physicians annual meeting over a five-year period (2013-2017)
Authors: Srivatsav V. , Zhang B. , Nadeem I. , Upadhye S. , Degroote Michael G.
Published: May 2018

Introduction: The CAEP annual meeting presents the latest evidence for clinical practice, but there has not yet been an appraisal of the abstracts presented at this conference. Therefore, we sought to evaluate the level of evidence of research presented at the annual meeting, and assess for trends over a five-year period (2013-2017). Methods: We conducted a scoping review that included all CAEP abstracts from 2013-2017, obtained through the Canadian Journal of Emergency Medicine. Two reviewers assessed eligibility and extracted data from abstracts individually, with conflicts resolved by a third reviewer. Qualitative research was excluded. Extracted data included type of presentation (ex. oral, poster), sample size, study design and type of study (therapeutic, prognostic, diagnostic, education, quality improvement, or systems-wide/economic analyses research). A level of evidence (LOE) was assigned using the 2011 Oxford Centre for Evidence-Based Medicine criteria. Results: Abstracts from 2014-2017 have been analyzed thus far, 1090 of which were eligible and 990 included. Inter-rater agreement for screening and data extraction was high ( value 0.87 and 0.84 respectively). Systems-wide/economic analyses research was the predominant type of study (28.6%, 283/990), followed by therapeutic (19.9%, 197/990) and education (19.9%, 195/990). The mean LOE was 2.81 (95% CI 2.77,2.85). The highest proportion of studies were of level III evidence (77.7%, 769/990), followed by level II (9.6%, 95/990) and level I evidence (7.8%, 77/990). 72.1% (124/172) of all level I and II abstracts were presented in 2016 and 2017. A significant change in LOE between years was evident (p<0.0001, chi-squared). The greatest proportion of level I and II abstracts were lightning oral (41.9%, 72/172), followed by posters (36.0%, 62/172). The best average LOE was observed for lightning oral (2.64, 95% CI 2.56, 2.72), with the poorest average LOE witnessed for moderated posters (2.90, 95% CI 2.83, 2.97). A significant difference was present in mean LOE between types of presentations (p<0.0001, one-sided ANOVA). Conclusion: The majority of abstracts were level III evidence. The lightning oral sessions had the greatest proportion of level I and II evidence presented. Recent years of the conference have also seen the presentation of a greater number of level I and II evidence, which may suggest a shift towards generating and disseminating higher level evidence in emergency medicine.
P147: Clinical characteristics and system factors of elderly treated for agitation in the emergency department: a data driven approach
Authors: Tam R. , McGregor K. , Maneshi A. , Gangatharan H. , Woo M. , Guan I. , Bradshaw K. , Bouchard M. , Meyers C.
Published: May 2018

Introduction: Aligning health systems appropriately to the needs of the elderly is an urgent global priority, according to the WHO. In Canada, ED length of stay has risen 16% for elderly patients in the last year. Agitation requiring chemical restraint is a common, high-risk problem for elderly in the ED. Improving outcomes in this heterogeneous population remain difficult due to inability to effectively identify and evaluate delirium, frailty, multi-morbidity, and incompatibility with the ED system. A data-driven approach to complex health problems is a recognized emerging tool for healthcare innovation. New opportunities for targeted quality improvement in the ED will be uncovered by identifying the clinical characteristics of elderly patients with agitation, and the system process factors that influence their outcomes. Methods: We studied 400 patients in a case-control study at two tertiary-care EDs over five years. Patients were randomly selected if age was greater than 75 years. 200 cases of patients who received an intravenous dose of haloperidol, midazolam and/or lorazepam were selected as a surrogate data marker for having agitation. Controls were randomly matched by age and ED diagnosis. Standardized clinical, systems and process variables were collected. We conducted a univariate analysis. Results: Elderly given intravenous medications for agitation had increased mortality (OR 3.8 CI: 1.6-10.7, p<0.001) and ED length of stay (27 vs. 15 hours, p<0.001). No statistical significance was found in clinical characteristics, CTAS scores, PRISMA7 frailty scores nor sentinel or return visits. There was no statistical difference in median hospital length of stay (8 vs. 6 days, p<0.70). No differences were found in median time from ED physician seeing a patient to first consultant request (73 vs. 83 mins, p=0.75). The largest time intervals contributing to ED length of stay were from first consultant request to hospital request (15 vs. 12 hours, p=0.056) and hospitalization delay (13 vs. 7 hours, p=0.45). Conclusion: Identification of high-risk elderly patients for targeted intervention through a data-driven approach is feasible and informative. Traditional clinical characteristics remain unhelpful in identifying and evaluating outcomes in elderly with agitation. We have identified a process factor that is clinically relevant and pragmatic to evaluate in our ED system. Future research focused on optimizing systems process factors to improve quality of elderly care should be prioritized.
P150: Emergency medicine resident perspectives on journal club as a community of practice and its impact on clinical medicine
Authors: Ting D. K. , Bailey B. , Scheuermeyer F. , Chan T. M. , Harris D. R.
Published: May 2018

Introduction: Despite revolutionary changes in the medical education landscape, journal club (JC) continues to be a ubiquitous pedagogical tool and is a primary way that residency programs review new evidence and teach evidence-based medicine. JC is a community of practice among physicians, which may help translate research findings into practice. Program representatives state that JC should have a goal of translating novel research into changes in clinical care, but there has been minimal evaluation of the success of JC in achieving this goal. Specifically, emergency medicine resident perspectives on the utility of JC remain unknown. Methods: We designed a multi-centre qualitative study for three distinct academic environments at the University of British Columbia (Vancouver, Victoria and Kelowna). Pilot testing was performed to generate preliminary themes and to finalize the interview script. An exploratory, semi-structured focus group was performed, followed by multiple one-on-one interviews using snowball sampling. Iterative thematic analysis directed data collection until thematic sufficiency was achieved. Analysis was conducted using a constructivist Grounded Theory method with communities of practice as a theoretical lens. Themes were compared to the existing literature to corroborate or challenge existing educational theory. Results: Pilot testing has revealed the following primary themes: (1) Only select residents are able to increase their participation in JC over the course of residency and navigate the transition from peripheral participant to core member; (2) These residents use their increased clinical experience to perceive relevance in JC topics, and; (3) Residents who remain peripheral participants identify a lack time to prepare for journal club and a lack of staff physician attendance as barriers to resident engagement. We will further develop these themes during the focus group and interview phases of our study. Conclusion: JC is a potentially valuable educational resource for residents. JC works as a community of practice only for a select group of residents, and many remain peripheral participants for the duration of their residency. Incorporation of Free Open-Access Medical Education resources may also decrease preparation time for residents and staff physicians and increase buy-in. To augment clinical impact, the JC community of practice may need to expand beyond emergency medicine and include other specialties.
P153: Preparedness of Canadian physician offices for paediatric emergencies
Authors: Verma S. S. , Weeraratne A. , Jeong D. , Atalla M. , Hassan-Ali M. , Kam A.
Published: May 2018

Introduction: Background: Studies in the US have demonstrated that many primary care staff and offices are inadequately prepared for paediatric emergencies. Although the Canadian Paediatric Society (CPS) recently reaffirmed their Guidelines for Paediatric Emergency Equipment and Supplies for a Physicians Office, no evaluation has been made regarding the impact of publishing these recommendations, or on the state of preparedness for paediatric emergencies in family physician offices. Objectives: The aim of this study was to evaluate awareness and adherence of family physicians in Ontario to the CPS guidelines on preparedness for paediatric emergencies. Methods: We conducted a province-wide, cross-sectional survey of 749 randomly selected family physicians. Participants were asked to complete a 14-question survey regarding clinic characteristics, incidence of paediatric emergencies, and preparedness of the clinic in the case of a paediatric emergency. Ethics approval was obtained from the regional Ethics Review Board. Results: 104 physicians responded to our Ontario survey (response rate of 14.8%). 71.2% of respondents reported seeing more than 10 children per week, and 58.7% and had experienced at least one paediatric emergency in the past year. The proportion of physicians reporting paediatric emergencies within the last year increased with the number of children seen - 37.9% of physicians who saw fewer than 10 children per week reported an emergency, compared to 85.7% of those who saw more than 40 children per week. 85.6% of respondents reported that they were unaware of the CPS guidelines on paediatric emergency preparedness. Only 9.6% of respondents were aware of the guidelines, and even fewer, 3.8% had read them. Of the physicians who were unaware of the guidelines, 4.5% [CI=0.2, -0.09] engaged in mock code sessions, 29.2% [CI=0.2, 0.2] were up-to-date on Paediatric Advanced Life Support (PALS), 1.1% [CI=0.03, -0.01] had written protocols outlining safe transport of children to hospitals, and 50.6% [CI=0.4, 0.6] stocked half or more of the recommended supplies. In comparison, of the physicians who were aware of the guidelines, 14.3% [CI=0.3, -0.04] engaged in mock code sessions, 35.7% [CI=0.1, 0.6] were up-to-date on PALS, 7.1% [CI=0.2, -0.06] had written protocols, and 78.6% [CI=0.8, 0.8] stocked half or more of the recommended supplies. Conclusion: A large proportion of respondents had experienced at least one paediatric emergency in the past year, but were overall underprepared. The majority of respondents, 85.6%, were not aware of the guidelines, compared to 9.6% who were aware of them. However, offices with the latter were more adherent to the guidelines recommendations. It will be important for CPS to consider how to further advocate for paediatric emergency preparedness in clinics that see children regularly.
P162: Patient-important outcomes in hyperglycemia after discharge from the emergency department: a prospective cohort study
Authors: Yan J. W. , Siddiqi L. , Van Aarsen K. , Columbus M. , Gushulak K. M.
Published: May 2018

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), carry significant morbidity for individuals even after discharge. The objective of this study was to describe the patient-important outcomes and burden of disease for emergency department (ED) patients with hyperglycemia after discharge from hospital. Methods: This was a prospective cohort study of patients 18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS over a 15-month period (Jul 2016-Oct 2017). During the ED visit, consent was obtained for a telephone follow-up call to determine patient-important outcomes. Trained research personnel collected data from medical records and completed a 14 day telephone follow-up using a standardized questionnaire to determine medication changes, missed days of school or work, and repeat admissions or visits to a healthcare provider. Descriptive statistics were used where appropriate to summarize the data. Results: Thus far, 172 patients have been enrolled in our study. Mean (SD) age is 53.9 (19.3) years and 97 (56.4%) are male. 65 (37.8%) patients were admitted from their initial ED visit. Of the 125 patients (72.7%) providing post-discharge outcomes, 75 (60.0%) required an adjustment to their diabetes medications or insulin. 21 (16.8%) patients missed days of school or work for a median (IQR) duration of 3.5 (1.3, 7.0) days. 85 (68.0%) saw another healthcare provider within a 14 day period, 45 (36.0%) saw their family physician, and 34 (27.2%) saw an internist or endocrinologist. 9 (7.2%) were seen again in the ED, 5 of these patients required admission to hospital. There was one death that occurred within the follow-up period. Conclusion: This prospective study builds on our previous retrospective work and demonstrates that visits for hyperglycemia carry a significant burden of disease beyond what may be seen in a single ED encounter. Further research will attempt to identify the factors that may be predictive of adverse outcomes in hyperglycemic patients presenting to the ED.
P167: The spot the diagnosis! series: using fine art to teach observation skills and medical concepts on a medical education website
Authors: Zhao L. , Maniuk T. , Chan T. M. , Thoma B.
Published: May 2018

Introduction: Fine art education increases the quality and quantity of observations that medical students make in both art and clinical reports. However, there are few free and accessible resources that teach art and observational skills to healthcare learners and providers. CanadiEM.org, a medical education blog, developed a new series called Spot the Diagnosis! to address this gap. The goals of the Spot the Diagnosis! series are to: 1) use art to explain medical concepts, 2) tie medical concepts to visual art, 3) hone observational skills, and 4) expose healthcare providers to art. Methods: Each piece of art for the Spot the Diagnosis! Series is selected based upon the author’s art history knowledge, resources found using an online search, and/or suggestions made by other healthcare professionals. The accompanying blog post is researched and written by a medical student in a question-and-answer style and peer-reviewed by another medical student and physician. Posts are uploaded monthly to CanadiEM.org and accessible to anyone with an internet connection. Promotion occurs on site, via email, word-of-mouth, and social media. Viewership is tracked using Google Analytics (GA). A survey for readers is planned to assess who, how, and why readers use the series, but results were not available prior to abstract submission. Results: Six Spot the Diagnosis! posts have been published, each of which begins with the selection of a piece of fine arts that showcases a potential medical diagnosis and a blog post outlining an interpretation of the work informed by observations, historical reports, and medical evidence. Each was published as a blog post on a Saturday and added to a page containing a list of all posts in the broader Arts PRN section on CanadiEM. All contained a single piece of art as the focus, 6 ± 2 (median ± IQR) questions, 638 ± 250 words, and 6 ± 3 references. The answers to questions are hidden under drop-down formatting to allow viewers to arrive at their own answers first. In the first 30 days of publication, each post in the series was viewed 1582 ± 401 times. Conclusion: The Spot the Diagnosis! series is an online educational resource published on CanadiEM.org that aims to improve learners medical knowledge and observational skills by featuring fine arts pieces with relevant question-and-answer style posts. This series fills the gap between art and medicine and has been well received by CanadiEM viewers. We look forward to analyzing responses in our survey to further understand how, why, and who uses this new and innovative resource.
P168: Critical dynamics study of burnout in emergency department health professionals in New Brunswick: revisiting 6 years later
Authors: Zhou F. , Howlett M. , Fraser J. , Stoica G. , Talbot J. , Atkinson P.
Published: May 2018

Introduction: Emergency Department (ED) staff burnout correlates with psychological coping strategies used by Emergency department health professionals (EDHPs). Staff at two urban referral EDs in New Brunswick took part in a survey of burnout and coping strategies after one ED experienced an influx of new physicians and a newly renovated ED in 2011. Six years later, ED crowding and EDHP staffing problems became prevalent at both EDs. We compared levels of burnout at two urban referral EDs to determine if burnout and coping worsened over time. Methods: An anonymous survey of all EDHPs at 2 urban referral EDs was performed in 2011 and in 2017. A demographics questionnaire, the Maslach Burnout Inventory (MBI, measuring emotional exhaustion, depersonalization and personal accomplishment), and the Coping Inventory for Stressful Situations (CISS, measuring task-oriented, emotion-oriented, and avoidance-oriented coping styles) were collected. Descriptive statistics and linear regression models examined relationships over time and between the two hospitals. Results: Burnout scores were similar both at the two facilities and in 2011 (n=153) and 2017 (n=127). There were no differences between samples or EDs for important factors. Emotion-oriented coping was associated with higher levels of burnout, while task-oriented coping was inversely correlated with burnout. Experiencing professional stress was a significant predictor of emotional exhaustion, while those working longer years in their current department had higher emotional exhaustion and depersonalization. By 2017, both EDs had experienced significant nursing staff turnover (50%) compared to 2011. Conclusion: Burnout scores remained consistent after 6 years at these two urban referral EDs. Given the evidence that increased years of service is associated with increased burnout, high staff turnover rate at both EDs could explain how scores remained constant. Staff turnover may represent a way these ED systems cope in a challenging environment. In 2017, task-oriented copers continued to score lower while emotionally-oriented copers showed higher burnout risk, and experiencing professional stress remains a strong predictor of burnout.
PL04: Effectiveness of hospital avoidance interventions among elderly patients: a systematic review
Authors: Ness A. , Symonds N. , Siarkowski M. , Broadfoot M. , McBrien K. , Lang E. S. , Holroyd-Leduc J. , Ronksley P.
Published: May 2018

Introduction: Overuse of acute care services, particularly emergency department (ED) use, is an important topic for healthcare providers and policy makers within Canada and abroad. Prior work has shown that frail elderly patients with complex medical needs and limited personal and social resources are heavy users of ED services and are often admitted when they present to the ED. Updated information on the most effective strategies to avert ED presentation and hospital admission focused specifically on elderly patients is needed. Methods: This systematic review addressed the question: what interventions have demonstrated effectiveness in decreasing ED use and hospital admissions in elderly patients? Comprehensive literature searches were conducted in databases including Ovid Medline, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials with no language or date restrictions. Citations were limited to interventional studies. Grey literature and reference list searches, as well as communication with experts in the field were performed. Consensus or a third reviewer resolved any disagreements. Original research regarding interventions conducted in populations 65 years or older with acute illness, either living in community or facility-living were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included: mortality, cost, and patient-reported outcomes such as health-related quality of life and functional status. Results: Forty-three relevant studies were identified including 22 randomized controlled trials (RCT), 2 cluster-RCT, 2 trials with non-random allocation, 4 before-after studies, 6 quasi-experimental studies, and 7 cohort studies. Intervention settings included: home visits (22), long-term care (7), outpatient or primary care clinics (8), and ED (3) or inpatient (3). Data characterization revealed that home-based, outpatient and/or primary care-based strategies reduced ED visits and hospitalizations, particularly those which included comprehensive geriatric assessments, home visits or regular face-to-face contact and interdisciplinary teams. Hospital-based models generally showed no difference in ED or inpatient service utilization. There was, however, considerable variability across individual studies with respect to reporting of outcomes, statistical analyses performed, and overall risk of bias. Conclusion: Various interventional strategies have been studied to avert ED presentation and hospital admission for frail elderly patients. More rigorous methodology and standardization of outcome measures is needed to quantitatively assess the effects of these programs.
LO08: PROM-ED: the development and testing of a patient-reported outcome measure for use with emergency department patients who are discharged home
Authors: Vaillancourt S. , Cullen J. , Linton D. , Fahmy A. Copti , Dainty K. , Hofstetter C. , Inrig T. , Laupacis A. , Maybee A. , McGowan M. , Schull M. J. , Seaton B. , Beaton D.
Published: May 2018

Introduction: Patient-reported outcome measures (PROM) are questionnaires that can be used to elicit care outcome information from patients. We sought to develop and validate the first PROM for adult patients without a primary mental health or addictions presentation receiving emergency department (ED) care and who were not hospitalized. Methods: PROM development used a multi-phase process based on national and international guidance (FDA, NQF, ISPOR). Phase 1: ED outcome conceptual framework qualitative interviews with ED patients post-discharge informed four core domains (previously published). Phase 2: Item generation scoping review of the literature and existing instruments identified candidate questions relevant for each domain for inclusion in tool. Phase 3: Cognitive debriefing existing and newly written questions were tested with ED patients post-discharge for comprehension and wording preference. Phase 4: Field and validity testing revised tool pilot tested on a national online survey panel and then again at 2 weeks (test-retest). Phase 5: Final item reduction using a Delphi process involving ED clinicians, researchers, patients and system administrators. Phase 6: Validation - psychometric testing of PROM-ED 1.0. Results: Four core outcome domains were defined in Phase 1: (1) understanding; (2) symptom relief; (3) reassurance and (4) having a plan. The domains informed a review of existing relevant questionnaires and instruments and the writing of additional questions creating an initial long-form questionnaire. Eight patients participated in cognitive debriefing of the long-form questionnaire. Expert clinicians, researchers and patient partners provided input on item refinement and reduction. Four hundred forty-four patients completed a second version of the long-form questionnaire (add in retest numbers) which informed the final item reduction process by a modified Delphi method involving 21 diverse contributors. The questionnaire was validated and underwent final revisions to create the 21 questions that constitute PROM-ED 1.0. Conclusion: Using accepted PROM instrument development methodology, we developed the first outcome questionnaire for use with adult ED patients who are not hospitalized. This questionnaire can be used to systematically gather patient-reported outcome information that could support and inform improvement work in ED care.
LO16: Showing your work: experiences with mind maps and faculty teaching
Authors: Gossack-Keenan K. L. , Chan T. M. , Gardiner E. , Turcotte M. , de Wit K. , Sherbino J.
Published: May 2018

Introduction: Cognitive processing theories postulate that decision making depends on both fast and slow thinking. Experienced physicians (EPs) make diagnoses quickly and with less effort by using fast, intuitive thinking, whereas inexperienced medical students rely on slow, analytical thinking. This study used a cognitive task analysis to examine EPs cognitive processes and ability to provide knowledge translation to learners. Methods: A novel mind mapping approach was used to examine how EPs translate their clinical reasoning to learners, when evaluating a patient for a possible venous thromboembolism (VTE). Nine EPs were interviewed and shown two different videos of a medical student patient interview (randomized from six possible videos). Results: EPs were asked to demonstrate their clinical approach to the scenario using a mind map, assuming they were teaching a learner in the Emergency Department. EPs were later re-interviewed to examine response stability, and given the opportunity to make clarifying or substantive mind map modifications. Maps were broken into component pieces and analyzed using mixed-methods techniques. A mean of 15.7 component pieces were identified within each mind map (standard deviation (SD) 7.8). Maps were qualitatively coded, with a mean of 2.8 clarifying amendments (e.g. adding a time course caveat) (SD 1.5-5.75) and 4.4 substantive modifications (e.g. changing the flow of the map) (SD 2-5). Conclusion: Resulting mind maps displayed significant heterogeneity in teaching points and the degree to which EPs used slow thinking. EPs frequently made fast thinking jumps, although learners could prompt slow thinking by questioning unclear points. This is particularly important as learners engage in cognitive apprenticeship throughout their training. An improved understanding of EPs cognitive processes through mind mapping will allow learners to improve their own clinical reasoning (Merrit et al., 2017). Educating EPs on these processes will allow modification of their teaching styles to better suit learners.