bluuebunny/crossref_metadata_2025 huggingface dataset:
MP39: Characteristics of clinical decision support tools that impact physician behaviour: a systematic review and meta-analysis
Authors: Memedovich K. A. , Grigat D. , Dowsett L. , Lorenzetti D. , Andruchow J. E. , McRae A. D. , Lang E. S. , Clement F.
Published: May 2018

Introduction:
Clinical decision support (CDS) has been implemented in many clinical settings in order to improve decision-making. Their potential to improve diagnostic accuracy and reduce unnecessary testing is well documented; however, their effectiveness in impacting physician practice in real world implementations has been limited by poor physician adherence. The objective of this systematic review and meta-regression was to establish the effectiveness of CDS tools on adherence and identify which characteristics of CDS tools increase physician use of and adherence. Methods: A systematic review and meta-analysis was conducted. MEDLINE, EMBASE, PsychINFO, the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to June 2017. Included studies examined CDS in a hospital setting, reported on physician adherence to or use of CDS, utilized a comparative study design, and reported primary data. All tool type was classified based on the Cochrane Effective Practice and Organization of Care (EPOC) classifications. Studies were stratified based on study design (RCT vs. observational). Meta-regression was completed to assess the different effect of characteristics of the tool (e.g. whether the tool was mandatory or voluntary, EPOC classifications). Results: A total of 3,359 candidate articles were identified. Seventy-two met inclusion criteria, of which 46 reported outcomes appropriate for meta-regression (5 RCTs and 41 observational studies). Overall, a trend of increased CDS use was found (pooled RCT OR: 1.36 [95% CI: 0.97-1.89]; pooled observational OR: 2.12 [95% CI: 1.75-2.56]).When type of tool is considered, clinical practice guidelines were superior compared to other interventions (p=.150). Reminders (p=.473) and educational interventions (p=.489) were less successful than other interventions. Multi-modal tools were not more successful that single interventions (p=.810). Lastly, voluntary tools may be supperior to than mandatory tools (p=.148). None of these results are statistically significant. Conclusion: CDS tools accompanied by a planned intervention increases physician utilization and adherence to the tool. Meta-regression found that clinical practice guidelines had the biggest impact on physician adherence although not statistically significant. Further research is required to understand the most effective intervention to maximize physician utilization of CDS tools.
MP40: Do doctors cherry pick?
Authors: Innes G. , Andruchow J. , McRae A. D. , Lang E.
Published: May 2018

Introduction: Physician access to presenting complaint information may lead to cherry picking if some patients are seen as more attractive than others. Our objective was to determine whether chief complaint CC descriptors are associated with differing wait time to MD, hence whether physicians preferentially see patients with selected presenting complaints. Methods: We collated administrative data on all Calgary ED patients from 2016. Those in CTAS categories 1 and 5 were excluded, as well as fast track patients (because of single coverage). We described most common chief complaint (CC) categories and their median wait time to MD, adjusted for ED arrival site, patient sex, triage acuity, and need for admission. Results: We studied 128,812 subjects (54% CTAS2, 46% CTAS34) with 56,243 males and 72,569 females. Mean age was 50.6 years (sd=20), and most common CC categories (%) were abdominal pain (22%), chest pain (14.6%), musculoskeletal problems (7.2%), flank pain (5.2%), URI/Fever (4.7%), dyspnea (4.6%), headache (4.6%), and back pain (4.0%). Median TTMD was 84 min and admission rate in the study cohort was 30.4%. Multiple linear regression modeling showed that, in addition to CC category and ED arrival site, CTAS level, female sex, and need for admission changed TTMD by 18.6 min (per CTAS level), 6.6 min, -19.2 min respectively. Based on adjusted TTMD, the least attractive CC categories (adjusted median TTMD) were constipation (104 min), back pain (103), Depression/anxiety (103), abdominal pain (102), and dizziness/sensory disturbance (98); while the most attractive were trauma (44 min), allergic reaction (46), stroke symptoms (49), palpitations (61), and overdoses (66). Conclusion: There is a larger than expected difference in waiting times associated with specific chief complaint categories. This has implications for the way that patients are assigned to physicians or perhaps the way that chief complaint data is transmitted.
MP42: Validation of the Stoplight Pain Scale tool in the Canadian emergency setting
Authors: Shwetz S. , Morrison E. , Drendel A. , Yaskina M. , Rajagopal M. , Estey A. , Ali S.
Published: May 2018

Introduction: Introduction: A variety of pain assessment tools exist for children, however none of the current scales were created specifically for family use. Further, none provide direct guidance with regards to pain treatment threshold. This study aimed to validate a novel, three faced, coloured coded (red, yellow, green), family-friendly pain tool, the Stoplight Pain Scale, by comparing it to the widely accepted and validated Faces Pain Scale-Revised (FPS-R). This novel tool has the capability to guide families with regards to treatment, as well as measure pain. Methods: Methods: A prospective observational cohort study was conducted at the Stollery Childrens Hospital emergency department (ED) (Edmonton, Alberta) from November, 2014 to February, 2017. Demographic information was collected, and patients (3-12 years) and their caregivers were asked to rate their pain using the novel Stoplight Pain Scale as well as the FPS-R. Pain was measured at presentation to the ED, immediately following painful procedures, and thirty minutes after analgesia administration. Patients and their caregivers also indicated their preferred scale for assessing pain. Results: Results: A purposeful random sample of 227 patients were included for analyses; 61/227 (26.9%) of patients were 3-5 years old and 166/227 (73.1%)were 6-12 years old. 53/227 (23.3%) of patients had been previously hospitalized. Correlation between the two pain scales was consistently fair to moderate; using Kappa Statistics, a baseline correlation for Stoplight and FPS-R was fair for both caregivers (0.38, 95% CI 0.28 0.48) and patients (0.36 95% CI 0.27-0.45). The Stoplight Pain Scale had fair to moderate correlation between caregiver and patient scores, (0.37, 95% CI 0.27-0.47), compared to FPS-R which showed poor to fair agreement between caregiver and child scores (0.20, 95% CI 0.12-0.29). Regardless of age or hospitalization status, 64% of patients (139/218) and 54% caregivers (118/220) preferred the Stoplight Pain scale (p=0.001). Conclusion: Conclusions: The Stoplight Pain Scale correlates moderately well with FPS-R, a validated pain assessment tool for children and shows good correlation between patients and caregivers assessment of reported pain. The Stoplight Pain Scale is a simple, easy to administer tool that may have a role in empowering family involvement in ED pain management. Future research should focus on at-home study of the tool.
P005: Optimum accuracy of massive transfusion protocol activation criteria: the clinician’s view
Authors: Bell C. , Davis P. , Prokopchuk-Gauk O. , Cload B. , Stirling A.
Published: May 2018

Introduction: Massive Transfusion Protocol (MTP) activation allows for efficient delivery of a balanced transfusion strategy to exsanguinating patients, and should deliver a reasonable ratio of plasma and platelets to red blood cells. MTP activation should facilitate communication between care providers and laboratory services in order to minimize blood product wastage. Unfortunately, it is unclear which activation criteria are best to achieve this. Understanding of acceptable sensitivity and specificity, as well as reasons for blood component wastage, may provide refinement to MTP design. Methods: We surveyed clinicians, who were identified as content experts in their fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 included Emergency Medicine, Anesthesia, Critical Care, and Surgery; Group 2 included Hematology, Hematopathology and Transfusion Medicine. Between-group differences were examined using the Pearsons Chi-Square Test. Statistical significance was set at p<0.05. Results: 50% of physicians in Group 1 considered an MTP under-call rate of 5-10% to be acceptable, whereas the majority (57.1%) of physicians in Group 2 considered an under-call rate of <5% to be acceptable. Both groups agreed on an acceptable over-call rate of 5-10%. A significantly greater proportion of physicians in Group 1 felt that MTP activation criteria including transfusion of an entire blood volume within 24 hours, loss of >50% blood volume within 3 hours and anticipated transfusion of >10U of PRBC in 24 hours were appropriate for MTP activation. Physicians in Group 2 were more likely to consider poor communication a reason for blood component wastage. Conclusion: Similarities in acceptable over- and under-call rates of MTP highlight the similar values in MTP activation between different medical specialties. Collaboration between the resuscitation team and consultants in transfusion medicine is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.
P008: Hereditary Angioedema Rapid Triage Tool (HAE-RT): translating clinical research into clinical practice
Authors: Betschel S. , Avilla E. , Waserman S. , Badiou J. , Binkley K. , Borici-Mazi R. , Hebert J. , Howlett L. , Kanani A. , Keith P. , Lacuesta G. , Yang W. , Rowe A. , Waite P.
Published: May 2018

Introduction: Hereditary angioedema (HAE) patients (both diagnosed and undiagnosed) commonly present to the emergency department (ED). Presenting symptoms (swelling and pain) may be erroneously attributed to common allergic and gastrointestinal conditions resulting in major delays in diagnosis and appropriate treatment. No published tools currently exist for HAE screening and management in undiagnosed disease. The overall goal of the study was to develop a HAE-RT tool for ED settings. Methods: A two-phase mixed methods approach was used to develop the HAE-RT Tool including: Phase 1: A Delphi Study [HAE specialists (N=9) and National Patient Advocacy Group Members (N=3)] was conducted to reach consensus (80% agreement) on predictor variables to include. Phase 2: A retrospective chart review was conducted to assess the predictive findings of the predictor variables. A convenient sample of patients presenting with angioedema (with and without HAE) between January 2012 January 2017 were included in the study. Results: Of the 12 experts invited, 9 (75%) participated in the Delphi study. Of 8 HAE-specific predictive variables, 4 reached consensuses including: (1) recurrent angioedema; (2) absence of urticaria; (3) past recurrent abdominal pain/swelling; (4) response to allergic therapy. The retrospective study included 85 patients (N=46 with HAE; N=39 non-HAE; overall 72% female). HAE patients were significantly more likely to have a family history of HAE (72% vs 0%; P<0.0001); previous recurrent angioedema (96%; P<0.009); present with no hives (91%; P<0.036); previous recurrent abdominal pain (80%; P<0.0001); and only 2% responded positively to allergy treatments (P<0.0001). Conclusion: Our study emphasizes the importance of key stakeholder involvement and feedback to facilitate the prioritization of important information that must be included in the design of an HAE-RT tool. The next step is to observe the effect of the HAE-RT tool on patient triage in the ED.
P010: A systematic review of the association between emergency medical services (EMS) time factors and survival
Authors: Blanchard I. , Patel A. , Lane D. , Couperthwaite A. , Chisholm D. , Yergens D. , Lazarenko G. , Lorenzetti D. , Lang E. , Doig C. , Ghali W.
Published: May 2018

Introduction: EMS time factors such as total prehospital, activation, response, scene and transport intervals have been used as a measure of EMS system quality with the assumption that shorter EMS time factors save lives. The objective was to assess in adults and children accessing ground EMS (population), whether operational time factors (intervention and control) were associated with survival at hospital discharge (outcome). Methods: Medline, EMBASE, and CINAHL were searched up to January 2015 for articles reporting original data that associated EMS operational time factors and survival. Conference abstracts and non-English language articles were excluded. Two investigators independently assessed the candidate titles, abstracts, and full text with discrepant reviews resolved by consensus. Risk of bias was assessed using GRADE. Results: A total of 10,151 abstracts were screened for potential inclusion, 199 articles were reviewed in full-text, and 73 met inclusion criteria. Amongst included studies, 49 investigated response time, while 24 investigated other time factors. All articles were observational studies. Amongst the 14 (28.6%) studies where response time was the primary analysis, statistically significant associations between shorter response time and increased survival were found in 5 of 7 cardiac arrest, 1 of 5 general EMS population, and 0 of 2 trauma studies. Other time factors were reported in the primary analysis in 10 (41.7%) studies. One study reported shorter combined scene and transport intervals associated with increased survival in acute heart failure patients. Two studies in trauma patients had somewhat conflicting results with one study reporting shorter prehospital interval associated with increased survival whereas the other reported increased survival associated with longer scene and transport intervals. Study design, analysis, and methodological quality were of considerable variability, and thus, meta-analyses were not possible. Conclusion: There is a substantial body of literature describing the association between EMS time factors and survival, but evidence informing these relationships are heterogeneous and complex. Important details such as patient population, EMS system characteristics, and analytical approach must be taken into consideration to appropriately translate these findings to practice. These results will be important for EMS leaders wishing to create evidence-based time policies.
P011: Performance of emergency department nurses in evaluating a simulated patient with alcohol withdrawal syndrome following an education curriculum
Authors: Borgundvaag B. , Thompson C. , McLeod S. , Perelman S. , Lee S.
Published: May 2018

Introduction: The optimal management of emergency department (ED) patients with alcohol withdrawal syndrome (AWS) includes a symptom driven approach with scheduled reassessments using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treatments according to symptom severity. The subjective nature of the CIWA-Ar, and lack of standardized competency-based education related to alcohol withdrawal results in widely variable treatment. The objective of this study was to perform a summative evaluation of clinical staff during the objective structured clinical examination (OSCE) of a simulated patient (SP) with AWS. Methods: The AWS education curriculum was completed by all staff nurses in our ED (mandatory for full-time, optional to part-time staff). It was based on a real clinical scenario depicting moderate alcohol withdrawal and portrayed by a single SP. Prior to the OSCE, participants attended a seminar orienting them to the simulation. Each participant was asked to do a complete assessment of the SP, and graded for completeness on 37 individual components of history/physical exam, including the 10 domains of the CIWA-Ar. Results: 74 participants completed the educational curriculum over 8 weeks. At least 9/10 domains of the CIWA-Ar assessment were completed by 65 (88%) of participants, and 28 (38%) correctly assessed at least 80% of all summative evaluation components. 63 (85%) participants correctly identified the need for treatment of withdrawal symptoms. Only 13 (18%) participant assessments exactly matched our exact target CIWA-Ar score of 15, however 61% were within 2 points on the CIWA-Ar scale. In only 4 (5%) instances would a participant have inappropriately rated AWS severity below the treatment threshold. 62/72 (86%) participants rated the SP tremor as 2-4 (intended tremor =3). Clinical features most often overlooked were history of other addictions (25 participants, 33%) and history of liver disease (15 participants, 20%). Conclusion: The majority of participants in this OSCE correctly assessed the important elements in the assessment of AWS, and diagnosed the SP as having moderate alcohol withdrawal. Thus our educational intervention resulted in 85% of participants properly identifying the severity of AWS, and developing an appropriate treatment strategy. The impact of this curriculum on actual patient treatment requires further evaluation.
P015: Staff skills: a procedural skills curriculum for emergency medicine attending physicians in Calgary
Authors: Chad A.F. , Baker L. , Johnston A. , Wishart I.M.
Published: May 2018

Introduction: Emergency medicine attending physicians perform many essential procedures but some infrequently. Skill proficiency and familiarity declines over time. We intended to identify skills where colleagues felt deficient and create an opportunity to demonstrate and practice in a safe environment. Methods: Sessions began from a review of ultrasound guided central line and pacemaker insertion. Other procedures have been added as a result of critical incidents, needs assessments by attending physicians, acquisition of new technology/equipment and expert consensus. An evaluation and needs assessment is performed after each session to adjust curricula. Results: Since 2011, we have held 2-3 skill sessions per year at the Advanced Trauma Surgical Skills Laboratory at the University of Calgary. Sessions are taught by attending emergency physicians, employ task trainers, simulators, animal and human cadaveric models, ultrasound, and procedural equipment stocked in our local hospitals. We are able to accommodate ~30 participants per session for 3 hours of rotating 7-8 participants through various stations. Every session has been fully attended with a wait list. Physicians register by email with preference given to new participants and those identified during clinical practice review of requiring remediation. Costs of sessions are covered by voluntary contribution to an emergency department physician support fund. Procedures practiced have included airway (basic, adjuncts, bronchoscopy, video laryngoscopy, surgical airway, chest tube), vascular access (ultrasound guided central venous insertion, transvenous pacemaker insertion, nerve blocks, IO insertion), surgical skills (thoracotomy, chest tube, canthotomy, surgical airway) and other percutaneous procedures (paracentesis, thoracentesis, nerve block, lumbar puncture). High fidelity skills videos were created to augment the sessions, available on the department website. Four point scale evaluations from our most recent session yielded 100% excellent rating for overall workshop and relevance to practice. The 6 facilitators performance received 100% excellent or good ratings. Conclusion: We have developed a fun, nonthreatening opportunity for attending physicians to practice infrequent but important ED procedures. The sessions are well received, well attended, foster collegiality, confidence and competence in performance of infrequent ED skills. Our model could be generalized to other centres.
P024: Sharing evidence, experiences and expertise: the value of networking to standardize emergency care for kids in Canada
Authors: Crockett L. K. , Leggett C. , Curran J. , Knisley L. , Ripstein J. , Brockman G. , Scott S. , Hartling L. , Jabbour M. , Johnson D. , Klassen T.
Published: May 2018

Introduction: TREKK is a national knowledge mobilization network of clinicians, researchers and parents aimed at improving emergency care for children by increasing collaborations between general and pediatric emergency departments (ED). This study aimed to determine patterns of knowledge sharing within the network and identify connections, barriers and opportunities to obtaining pediatric information and training. Methods: Social network analysis (SNA) uses network theory to understand patterns of interaction. Two SNAs were conducted in 2014 and 2015 using an online network survey distributed to 37 general EDs. Data was analyzed using UCI Net and Netdraw to identify connections, knowledge sharing and knowledge brokers within the network. Building on these results, we then conducted 22 semi-structured follow-up interviews (2016) with healthcare professionals (HCPs) at General EDs across Canada, purposefully sampled to include individuals from connected and disconnected sites, as identified in the SNA. Interviews were analyzed by 2 reviewers using content and thematic analysis. Results: SNA data was analyzed for 135 participants across the network. Results from 2014 showed that the network was divided along provincial lines, with most individuals connecting with colleagues within their own institution. Results from 2015 showed more inter-site interconnectivity and a reduction in isolated sites over time from 17 to 3. Interview participants included physicians (59%) and nurses (41%) from 18 general EDs in urban (68%) and rural/remote (32%) Canada. HCPs sought information both formally and informally, by using guidelines, talking to colleagues, and attending pediatric related training sessions. Network structure and processes were felt to increase connections, support practice change, and promote standards of care. Participants identified personal, organizational and system-level barriers to information and skill acquisition, including resources and personal costs, geography, dissemination, and time. Providing easy access to information at the point of care was promoted through enhancing content visibility and by embedding resources into local systems. There remains a need to share successful methods of local dissemination and implementation across the network, and to leverage local professional champions such as clinical nurse liaisons. Conclusion: This study highlights the power of a network to increase connections between HCPs working in general and pediatric EDs. Findings reinforce the critical role of ongoing network evaluation to improve the design and delivery of knowledge mobilization initiatives.
P025: Are we ready for a gunman in the emergency department? A qualitative study of staff perceptions of risk and readiness to respond
Authors: McGowan M. , Dainty K. , Seaton B. , Gray S.
Published: May 2018

Introduction: Hospital-based gun violence is devastatingly traumatic for everyone present and recent events in Cobourg, Ontario underscore that an active shooter inside the emergency department (ED) is an imminent threat. In June 2016, the Ontario Hospital Association (OHA) added Code Silver to the list of standardized emergency preparedness colour codes and advised member hospitals to develop policies and train staff on how best to respond. Given that EDs are particularly susceptible to opportunistic breach by an active shooter, the impact of a Code Silver on ED functioning and staff members may be particularly acute. We hypothesized that there may not be a simple, one-size-fits-all-hospital-staff solution about how best to prepare EDs to respond to Code Silver. In order to inform and support future staff training initiatives related to Code Silver and other disaster situations in hospitals, we sought to investigate staff perspectives and behaviour related to personal safety at work and, in particular, an active shooter. Methods: We undertook a qualitative interview study of multi-disciplinary ED staff (MDs, RNs, clericals, allied health, administrators) at a single tertiary care centre in Toronto. The primary methods for data collection were in-depth qualitative interviews and focus groups. Participants were recruited using stakeholder and maximum variation sampling strategies. Data collection and analysis were concurrent and standard thematic analysis techniques were employed. Results: Sixteen (16) staff members participated in interviews and 40 participated in small focus group discussions. Data analysis revealed workplace violence and personal health risks have been normalized as expected, acceptable features of everyday life at work in the ED given that patients are perceived to be sick people in need of help that ED staff are trained for and prepared to provide. In contrast, weapons and active shooters challenge the boundaries of professional responsibility and readiness to respond to Code Silver is perceived by staff as a fallacy. Conclusion: Knowledge from this study gives us crucial insight into important areas for targeted training and opportunities for knowledge translation on the topic of implementing Code Silver in EDs across the country. Future interventions must include how to overcome normalization of workplace violence in the ED setting and negotiating competing professional obligations during crisis situations. Attention to these are crucial if we are to truly keep our staff safe during these traumatic events.
P028: Self-directed learning in advanced care paramedics: perceived deficits and completed activities
Authors: Davis M. , Leggatt L. , Romano S. , Van Aarsen K.
Published: May 2018

Introduction: In Ontario, Advanced Care Paramedics (ACPs) are required to perform a minimum of 24 educational credits per year of Continuing Medical Education (CME). Of these 24 credits, 12 are chosen by the paramedic, while 12 credits are mandated by the Base Hospital. The combined mandatory and optional CME frame is used so paramedics can target their personal needs appropriately, while ensuring new medical directives and global knowledge deficits identified by Quality Assurance (QA) means can be addressed by the Base Hospital. Objective: To determine if there is a difference between what ACPs identify as their knowledge deficits and what CME they complete. Methods: Methods: Request for participation in a written survey was delivered to all ACPs in an Ontario Base Hospital, prior to the CME cycle for the year. Respondents were asked to identify deficits from a 37-point, organ systems-based list, with free-text option for any deficits not itemized. Following the annual cycle, CME credits were evaluated by the Regional Base Hospital education coordinator, and Base Hospital medical directors for content. The deficits identified prior to the CME cycle were then compared to the CME attended for each respondent. In order to best represent the individual ACP response to their perceived deficits, a percentage of deficits identified and addressed was chosen. Respondents were not aware that their responses would be compared to the credits obtained for the year, to minimize bias in CME selection. Results: Of the 140 ACPs in the region, 42 (30%) completed the survey. From the 37-point list, the median number of perceived deficits identified was 7.00 (IQR 3.00-10.00). The median number of CME events that addressed perceived deficits was 2.00 (IQR 1.00-3.00). The median number of perceived deficits addressed by either paramedic-chosen or mandatory CME were identical at 1.00 (IQR 0.00-2.00). The percentage of perceived deficits identified and addressed via CME was 35.07% (range 0-100%). Paramedic-chosen CME covered 22.48% (range 0-100%) of perceived deficits, while mandatory CME covered 20.14% (range 0-100%) of perceived deficits. Conclusion: In the current system, only 35.07% of perceived deficits were addressed through mandatory and paramedic-chosen CME. Further information regarding barriers to paramedics obtaining CME that meets their perceived deficits needs to be elucidated.
P030: Role of scribes in emergency care in the Saskatoon health region
Authors: Dick A. B. , Olszynski P. , Behl V.
Published: May 2018

Introduction: Increasingly, hospitals are adopting electronic charting systems. Recent literature suggests that physicians are spending roughly 2:1 hours on charting as compared to actual patient care raising questions as to whether manual electronic charting is the best use of scarce physician resources. To counter these effects, some hospitals have introduced scribes into their departments. A medical scribe is a person, or paraprofessional, who specializes in charting physician-patient encounters in real time. In this pilot study, we assessed the impact of having a scribe on the mental and physical fatigue, patient and healthcare-team engagement, and overall work satisfaction of emergency physicians at an urban emergency department (St. Paul’s Hospital, Saskatoon). Methods: Three research participants (emergency physicians) were recruited to the study. Each participant completed a typing test to determine typing skills. The student researcher then provided scribe services for each participant for two shifts. The scribe charted physician-patient interactions in real time and also completed order sets, wrote orders, imaging requisitions, and prescriptions. Physicians completed surveys after each shift with the scribe as well as after 2 shifts without a scribe (for a total of 12 shifts in the study, 6 with the intervention). Physicians were asked to rate their mental and physical fatigue, enjoyment of work, and impact on patient/team engagement on a 10-point Likert scale. Results from the questionnaires were analyzed to determine individual and group mean responses. Given the small sample size, no further statistical calculations were completed. Results: Typing test results (in words per minute) were as follows: Scribe 93, Physician A 64, Physician B 40, Physician C 25. In terms of both mental and physical fatigue post shift, all 3 participants recorded being less fatigued after working shifts with a scribe. Mean group scores were as follows: mental fatigue decreased by 33%, physical fatigue decreased by 23%. Physicians work enjoyment improved by 10%. Team and patient interaction did not seem impacted by the intervention. Conclusion: It appears that regardless of typing skills, all physician participants noted a measurable benefit from having a scribe on shift. This suggests that off-loading documentation to the scribe has a positive effect on mental and physical endurance. These results warrant further investigations.
P035: Continuous intravenous low-dose ketamine infusion for managing pain in the emergency department
Authors: Drapkin J. , Motov S. , Likourezos A. , Beals T. , Monfort R. , Fromm C. , Marshall J.
Published: May 2018

Introduction: To describe dosing, duration, and pre- and post-infusion analgesic administration of continuous intravenous sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful conditions in the emergency department (ED). Methods: Retrospective chart review of patients aged 18 and older presenting to the ED with acute and chronic painful conditions who received continuous SDK infusion in the ED for a period over 6 years (2010-2016). Primary data analyses included dosing and duration of infusion, rates of pre- and post-infusion analgesic administration, and final diagnoses. Secondary data included pre- and post-infusion pain scores and rates of side effects. Results: 104 patients were enrolled in the study. Average dosing of ketamine infusion was 11.26 mg/hr, the mean duration of infusion was 135.87 minutes with 38% increase in patients not requiring post-infusion analgesia. The average decrease in pain score was 5.04. There were 12 reported adverse effects with nausea being the most prevalent. Conclusion: Continuous intravenous SDK infusion has a role in controlling pain of various etiologies in the ED with a potential to reduce need for co-analgesics or rescue analgesic administration. There is a need for more robust, prospective, randomized trials that will further evaluate the analgesic efficacy and safety of this modality across wide range of pain syndromes and different age groups in the ED.
P039: Application of the Delphi method to refine key components in the iterative development of a mobile tele-simulation unit (MTU)
Authors: Dunne C. , Jewer J. , Parsons M.
Published: May 2018

Introduction: Safe and efficient provision of quality healthcare requires maintenance of knowledge and skills relevant to daily practice. This is particularly relevant in rural and remote locations where high-acuity low-occurrence procedures and clinical scenarios present even less frequently. Simulation based training is widely used to supplement clinical exposure and practice but effective delivery of this approach to the rural/ remote practitioner must address barriers of time, cost and geographical separation. Mobile tele-simulation is an innovative approach that may help in bridging the gap through delivery of effective mentoring using telemedicine technologies and tailored educational content. Methods: To help direct the iterative design cycle for the mobile tele-simulation unit, input from potential future users was felt to be essential. The Delphi method was employed to reach consensus among study participants on four key questions: 1) What applications would the MTU be best suited for?, 2) What technical requirements and teaching tools would be needed to make the MTU successful?, 3) Which fields, besides EM/medical education, may benefit from partnerships with the final MTU?, 4) What research studies could be developed using the MTU? It was decided in advance that two rounds would be the maximum due to time constraints of the larger MTU projects. The first questionnaire focused on demographics and the four questions above. Independent reviewers analyzed, compiled and compared responses. Participants were sent the updated list, asked to confirm their responses and then to rank the responses highest to lowest priority. Results: Fifteen of 17 first round participants completed the questions, giving an 88.2% response rate. All shared a simulation background. 66% were physicians, 13.3% medical students, and 20% staff at Memorials Simulation Center. 66% had been involved with simulation-based education less than 5 years, and the others greater than 5 year. 13 of 15 (86.7%) responded in round 2. Consensus was not reached statistically using Kendalls W test for each of the four questions. However, there were several responses that showed higher median ranks than the others under each question. Application use: rural healthcare training, and medical professional training Technical factors: reliable learner-mentor connection, and competent technical support Non-technical factors: knowledgeable mentor and content relevant to locations practice, Research studies: training needs assessment from rural sites, and learners experience compared to stationary simulation center Conclusion: Input from a heterogeneous group of simulation users was sought to help prioritize key features in the development of the Mobile Tele-simulation Unit. Although statistically the study did not reach consensus, valuable feedback was compiled and pragmatically applied in the iterative development cycle.
P042: Resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma: a systematic review
Authors: Eksteen A. , Odenbach J. , Archer C. , Domke C.
Published: May 2018

Introduction: Trauma leading to uncontrolled hemorrhage of the torso in the critically injured patient can rapidly progress to decreased cerebral and cardiovascular perfusion and carries a significant morbidity and mortality. Given the non-compressible nature and difficult anatomic access of these injuries, obtaining hemostasis is often a challenge and non-surgical options are sparse. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a rapidly administered emergency department intervention that allows transient source control of caudal torso hemorrhage while arranging definitive surgical management. Although initially postulated in the 1950s, limited research regarding its therapeutic use in trauma has been available until recently. Here, we present a systematic review of the literature pertaining to the use of REBOA in severe trauma. Methods: An experienced medical librarian searched electronic databases for terms relating to REBOA, aortic balloon occlusion, hemorrhage, trauma and shock. Articles were identified, screened, retrieved and reviewed in accordance with PRISMA systematic review guidelines. English case reports, case series, cohort studies, randomized-controlled trials, systematic reviews and meta-analyses pertaining to the use of REBOA in human trauma patients were included. Customized inclusion and data extraction forms were created and used to form an electronic database of relevant studies. Results: After exclusion of duplicates, 2147 potentially relevant articles were identified and screened by title/abstract and 136 articles meeting inclusion criteria were retrieved for full-text review. Final analysis of 26 articles included 5 case reports, 13 case series, 7 observational cohort studies and 1 systematic review. Data spanning 771 patients undergoing REBOA were collected (weighted average age: 49.5, gender: 67.7% male, injury severity score: 35.1). Where data available, REBOA increased systolic blood pressure by a weighted average of 54.7mmhg and overall survival was 32.6%. Conclusion: Limited evidence pertaining to the use of REBOA in severe trauma exists with the majority of available data coming from individual case studies and case series. By extension, quantitative analysis regarding outcome data of this intervention requires further research in the form of larger studies with subgroup analysis to identify the subset of patients for which REBOA may benefit and to further delineate the risks of implementing this intervention
P045: Impact of post-intubation hypotension on mortality of patients in the emergency department (ED)
Authors: Emond M. , Turgeon J. , Shields J. , Nadeau A.
Published: May 2018

Introduction: Endotracheal intubation is frequently used in emergency departments and is often life saving, but it is also known to cause adverse events that can potentially lead to death. The main objective of this study is to evaluate mortality rates and duration of hospitalisation in patients who experienced post-intubation hypotension (PIH). Methods: A historical cohort of patients admitted between 07/2011 and 11/2014 at the ED of a level-one trauma centre. Patients were included if they were aged 16 years old or more, were intubated in the resuscitation room,had less than 3 intubation attempts, no need of surgical airway access, and had recorded vital signs prior to intubation. All clinical data including vitals were prospectively collected using ReaScribe®. PIH was defined by one measure or more of systolic arterial blood pressure <90 mm Hg. We retrospectively analysed the occurrence of PIH at 4 time points : 5, 15, 30 minutes, and at any moments after intubation. Study outcomes were in-hospital death and hospital length of stay in days (LOS). Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: 261 patients were included in the analyses. Amongst patient who experienced PIH, incidence of mortality was, respectively for each time estimate, of 31,0%, 33,3%, 28,6% and 26,9 % compared to 25,4% (p=0,5), 24,2% (p=0,1), 24,9% (p=0,5), and 25,4 % (p=0,8) in the normotensive group. The mean duration of hospitalisation in the group exposed to PIH was respectively of 26 (12,9-53,3), 22 (13,5-35,5), 19 (13,6-27,8), and 18 days (13.5-24.8) compared to 15,6 (12,9-18,9), 15,4 (12,6-18,8), 15,3 (12,3-19,1), and 15,5 (12.1-19.7) days (p=0,4). Conclusion: There was no association between the presence of post-intubation hypotension at 4 different time estimates and the in-hospital mortality nor the hospital length of stay. Further evaluation in specific sub-group should be foreseen to prevent adverse events from endotracheal intubation.
P046: A quality improvement initiative for improving integration of resource stewardship concepts into undergraduate medical education
Authors: Eppler K. , Pendrith C. , Wishart E. , Goodyear D. , Jenkins D. , Cheng E.
Published: May 2018

Introduction: It is estimated that up to 30% of medical services in Canada are potentially unnecessary, not supported by current evidence or may cause patient harm. This type of practice negatively impacts patients and the healthcare system. Evidence suggests that medical education strongly impacts resource utilization in future practice. Our objective was to integrate Choosing Wisely (CW) recommendations into the undergraduate medical education curriculum to improve students understanding of resource stewardship in their pre-clerkship training. Methods: Post-course survey data and written feedback were collected from the Cumming School of Medicines 2019 class. Qualitative analysis of written feedback was used to identify perceived strengths and areas of improvement to inform additional changes for the 2020 class through a Plan-Do-Study-Act (PDSA) cycle. Results: The post-course survey was completed by 143 students. 60% reported the inclusion of CW improved their ability to develop a clinical management plan. Using the information gathered from the qualitative analysis, we made the following changes for the 2020 class: create an introductory lecture on resource stewardship, incorporate relevant CW recommendations into case study learning objectives, and create standardized slides on CW recommendations for lecturers. Feedback from the 2020 class revealed that the changes were well received and students reported feeling more comfortable with resource stewardship concepts. Conclusion: This data reveals that our efforts have increased students confidence in creating a management plan that integrates resource stewardship and patient safety, and elicited strong faculty support. We will continue to integrate these changes and to obtain student and faculty feedback to help inform additional iterative changes for the subsequent cohort. Our findings are valuable for other medical schools across Canada seeking to incorporate CW material.
P047: Prevalence and severity of hypertension presenting to Calgary area emergency departments
Authors: Eppler K. , Wang D. , Pollak T.P. , Lang E.S.
Published: May 2018

Introduction: Hypertension is common and a major cause of morbidity and mortality. Because it is asymptomatic, its diagnosis is often delayed. For many Canadians the Emergency Department (ED) is the only point of entry to the health care system, and therefore the recognition of undiagnosed and untreated hypertension in the ED is increasingly important. This study sought to evaluate the prevalence and severity of hypertension in patients presenting to Calgary area EDs, as well as to determine whether medical therapy was initiated and if patients had primary care providers for follow-up. Methods: Multi-centre electronic medical record (EMR) review of all adult patients presenting to Calgary area EDs from January 1, 2016 to December 31st, 2016. Hypertension was coded electronically by triage nurses and defined as systolic blood pressure SBP 140 mmHg and/or diastolic blood pressure DBP 90 mmHg. Hypertensive urgency was defined as SBP 180 mmHg and/or DBP 120 mmHg. Descriptive data was used to show patient demographics and hypertension prevalence. Primary care provider status, previous diagnosis of hypertension, chief complaint, and ED diagnoses were extracted and the EMRs were manually searched to determine whether treatment was initiated in the ED. Results: Of 304392 patients presenting to all Calgary sites, 43055 (14%) were found to have hypertension; mean age 52 (range 18 to 104), female 42%. Of these, 32986 (77%) had no known previous hypertension and 31% lacked a primary care provider. 0.2% had documentation of treatment initiated in the ED. 16% met criteria for hypertensive urgency. Conclusion: Many patients presenting to the ED have hypertension, often previously undiagnosed and at times severe. Many lack access to primary care. EDs may play an important role in the early recognition of hypertension. Dedicated management and follow-up pathways are indicated for this high-risk population.
P061: Implementing CBME in emergency medicine: lessons learned from the first 6 months of transition at Queens University
Authors: Hall A. K. , Rich J. , Dagnone J. , Weersink K. , Caudle J. , Sherbino J. , Frank J. R. , Bandiera G. , Van Melle E.
Published: May 2018

Introduction: The specialist Emergency Medicine (EM) postgraduate training program at Queens University implemented a new Competency-Based Medical Education (CBME) model on July 1 2017. This occurred one year ahead of the national EM cohort, in the model of Competence By Design (CBD) as outlined by the Royal College of Physicians and Surgeons of Canada (RCPSC). This presents an opportunity to identify critical steps, successes, and challenges in the implementation process to inform ongoing national CBME implementation efforts. Methods: A case-study methodology with Rapid Cycle Evaluation was used to explore the lived experience of implementing CBME in EM at Queens, and capture evidence of behavioural change. Data was collected at 3- and 6- months post-implementation via multiple sources and methods, including: field observations, document analysis, and interviews with key stakeholders: residents, faculty, program director, CBME lead, academic advisors, and competence committee members. Qualitative findings have been triangulated with available quantitative electronic assessment data. Results: The critical processes of implementation have been outlined in 3 domain categories: administrative transition, resident transition, and faculty transition. Multiple themes emerged from stakeholder interviews including: need for holistic assessment beyond Entrustable Professional Activity (EPA) assessments, concerns about the utility of milestones in workplace based assessment by front-line faculty, trepidation that CBME is adding to, rather than replacing, old processes, and a need for effective data visualisation and filtering for assessment decisions by competency committees. We identified a need for administrative direction and faculty development related to: new roles and responsibilities, shared mental models of EPAs and entrustment scoring. Quantitative data indicates that the targeted number of assessments per EPA and stage of training may be too high. Conclusion: Exploring the lived experience of implementing CBME from the perspectives of all stakeholders has provided early insights regarding the successes and challenges of operationalizing CBME on the ground. Our findings will inform ongoing local implementation and higher-level national planning by the Canadian EM Specialty Committee and other programs who will be implementing CBME in the near future.