bluuebunny/crossref_metadata_2025 huggingface dataset:
LO03: Validation of The Ottawa Troponin Pathway
Authors: Lam B. , Li J. , Mukarram M. , Nemnom M. , Booth R. , Thiruganasambandamoorthy V.
Published: May 2019

Introduction: Our team developed “The Ottawa Troponin Pathway” (OTP) for Non-ST Elevation Myocardial Infarction (NSTEMI) diagnosis using serial conventional troponin (cTnI) 3 hours apart to aid in safe and early disposition of ED patients. The primary objective of this study is to validate the diagnostic accuracy of the OTP in the cohort of patients with cTnI values above the 99th percentile ( > 45ng/L). Methods: This study is a health records review conducted at the Civic and General Campuses of The Ottawa Hospital from August 2017 to December 2017. Adults (≥18 years) who presented to the ED with symptoms of ACS, and who had serial cTnI (at least two values 3 hours ±15 minutes apart) performed for diagnosis of NSTEMI and at least one cTnI value > 45ng/L were included. Patients with cardiac arrest, STEMI, unstable angina or those with TnI values ≤45ng/L were excluded. The outcomes were death due to unknown cause or NSTEMI adjudicated by two blinded investigators within 30 days. Data collected include baseline characteristics, ED management, length of stay, cTnI values and times of measurement, disposition, and outcome. We used descriptive statistics and test diagnostic characteristics to analyze our data. Results: We screened 53,077 patients, of whom 635 patients were included in the study (mean age 71.6 years; 57.6% males; 59.7% hospitalized; median ED length of stay 4.7 hours.). 107 patients (16.9%; 95%CI 14.1%-20.0%) were diagnosed with NSTEMI within 30 days. Among patients with TNI values above the 99th percentile, the OTP did not miss any patients diagnosed with NSTEMI. The sensitivity and the specificity of the OTP were 100% (95%CI 96.6%-100%) and 32.2% (95%CI 28.2%-36.4%) respectively. Conclusion: Our results show that the OTP is diagnostically accurate in ruling out NSTEMI among patients with cTNI values above the 99th percentile with symptoms concerning for ACS. Using the OTP will allow for early referral to consulting services for management, safe and early discharge home, and improve ED crowding.
LO05: Influence du délai avant le retour de circulation spontanée sur la survie des patients souffrant d'un arrêt cardiaque extrahospitalier
Authors: Cournoyer A. , Cossette S. , Daoust R. , Morris J. , Chauny J. , Potter B. , de Montigny L. , Ross D. , Londei-Leduc L. , Lamarche Y. , Paquet J. , Marquis M. , Notebaert É. , Albert M. , Piette É. , Cavayas Y. , Denault A.
Published: May 2019

Introduction: Parmi les patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH), ceux ayant un retour de circulation spontanée (RCS) durant la phase préhospitalière de leur réanimation ont un meilleur taux de survie. Il est plausible que les patients ayant un RCS plus précocement durant leur réanimation préhospitalière aient de meilleur taux de survie que les patients ayant un RCS plus tardif. Cette étude visait à décrire l'association entre la survie et la durée de la réanimation par les paramédics avant le RCS préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Tous les patients adultes avec un RCS préhospitalier suite à un ACEH d'origine médicale ont été inclus. Les patients ayant eu un arrêt devant les paramédics ont été exclus, tout comme ceux avec un RCS avant l'arrivée des services préhospitaliers. L'association entre la survie et le temps de réanimation avant le RCS a été évaluée à l'aide d'une régression logistique multivariée ajustant pour les variables sociodémographiques et cliniques pertinentes (âge, sexe, rythme initial, heure de l'appel initial, arrêt témoigné, manœuvre par témoin, présence de premiers répondants ou de paramédics de soins avancés, délai avant l'arrivée des intervenants préhospitaliers). Results: Un total de 1194 patients (818 hommes et 376 femmes) d'un âge moyen de 64 ans ( ±17) ont été inclus dans l’étude, parmi lesquels 433 (36%) ont survécu jusqu’à leur congé hospitalier. Le délai moyen avant leur RCS était de 17 minutes ( ±12). Nous avons observé une association indépendante entre la survie au congé hospitalier et le délai avant le RCS préhospitalier (rapport de cotes ajusté = 0,91 [intervalle de confiance à 95% 0,89-0,92], p < 0,001). Plus de 50% des survivants avaient obtenu un RCS moins de 9 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 95% avant 26 minutes. Aucun (0%) des 17 patients ayant eu un RCS plus de 56 minutes après l'initiation de la réanimation préhospitalière n'a survécu. Conclusion: Un RCS précoce semble être un facteur de bon pronostic parmi les patients souffrant d'un ACEH. La majorité des patients avec un RCS préhospitalier allant survivre à leur hospitalisation ont obtenus leur RCS dans les 9 minutes suivant l'initiation des manœuvres de réanimation.
LO08: Defibrillation energy dose during pediatric cardiac arrest: systematic review of human and animal model studies
Authors: Mercier E. , Laroche E. , Beck B. , Le Sage N. , Cameron P. , Emond M. , Berthelot S. , Mitra B. , Ouellet-Pelletier J.
Published: May 2019

Introduction: Prompt defibrillation is critical during paediatric cardiac arrest. The main objective of this systematic review was to determine the initial defibrillation energy dose for ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) that is associated with sustained return of spontaneous circulation (ROSC) during paediatric cardiac arrest. Associations between initial defibrillation energy dose with any ROSC, survival and defibrillation-induced complications were also assessed. Methods: A systematic review was performed using four databases (Medline, Embase, Web of Science, Cochrane Library) (PROSPERO: CRD42016036734). Human studies (cohort studies or controlled trials) and animal model studies (controlled trials) of pediatric cardiac arrest involving assessment of external defibrillation energy dosing were considered. The primary outcome was sustained ROSC. Two researchers independently reviewed all the titles and abstracts of the retrieved citations, selected the studies and extracted the data using a standardized template. Risk of bias of human non-randomised studies were assessed using the ROBIN-I tool (formerly ACROBAT-NRSI) tool proposed by the Cochrane Collaboration group. Results: The search strategy identified 14,471 citations of which 232 manuscripts were reviewed. Ten human and 10 animal model studies met the inclusion criteria. Human studies were prospective (n = 6) or retrospective (n = 4) cohort studies and included between 11 and 266 patients (median = 46 patients). Sustained ROSC rates ranged from 0 to 61% (n = 7). No studies reported a statistically significant association between the initial defibrillation energy dose and the rate of sustained ROSC (n = 7) or survival (n = 6). No human studies reported defibrillation-induced complications. Meta-analysis was not considered appropriate due to clinical heterogeneity. The overall risk of bias was moderate. All animal studies were randomized controlled trials with 8 and 52 (median = 27) piglets. ROSC was frequently achieved (more than 85%) with energy dose ranging from 2 to 7 joules/kg (n = 7). The defibrillation threshold varied according to the body weight and appears to be higher in infant models. Conclusion: Defibrillation energy doses and thresholds varied according to the body weight and trended higher for infants. No definitive association between initial defibrillation doses and the outcomes of sustained ROSC or survival could be demonstrated.
LO09: Variation entre les taux de retour de circulation spontané préhospitalier et les délais de réanimation avant ceux-ci en fonction du rythme initial chez les patients souffrant d'un arrêt cardiaque extrahospitalier
Authors: Cournoyer A. , Cossette S. , Daoust R. , Chauny J. , Potter B. , Marquis M. , Morris J. , de Montigny L. , Ross D. , Lamarche Y. , Londei-Leduc L. , Paquet J. , Notebaert É. , Albert M. , Bernard F. , Piette É. , Cavayas Y. , Denault A.
Published: May 2019

Introduction: Les patients ayant un retour de circulation spontanée (RCS) durant la phase préhospitalière de leur réanimation suite à un arrêt cardiaque extrahospitalier (ACEH) ont un meilleur taux de survie que ceux n'en ayant pas. La durée des efforts de réanimation avant l'initiation d'un transport ne varie généralement pas en fonction du rythme initial observé. Cette étude vise à comparer la durée des manœuvres de réanimation nécessaire afin de générer la majorité des RCS préhospitaliers et des RCS préhospitaliers menant à une survie en fonction du rythme initial. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients avec un ACEH d'origine médicale ont été inclus. Les patients dont l'ACEH était témoigné par les paramédics ont été exclus, tout comme ceux dont le rythme initial était inconnu. Nous avons comparé entre les groupes (rythme défibrillable [RD], activité électrique sans pouls [AESP] et asystolie) les taux de RCS préhospitalier et le temps nécessaires pour obtenir une majorité des RCS préhospitaliers et des RCS préhospitaliers menant à une survie. Results: Un total de 6002 patients (3851 hommes et 2151 femmes) d'un âge moyen de 52 ans ( ±10) ont été inclus dans l’étude, parmi lesquels 563 (9%) ont survécu jusqu’à leur congé hospitalier et 1310 (22%) ont obtenu un RCS préhospitalier. Un total de 1545 (26%) patients avaient un RD, 1654 (28%) une AESP et 2803 (47%) une asystolie. Les patients avec un RD ont obtenu plus fréquemment un RCS préhospitalier et un RCS préhospitalier menant à une survie que les patients avec une AESP qui eux même avaient un meilleur pronostic que ceux avec une asystolie initial (777 patients [55%] vs 385 [23%] vs 148 [5%], p < 0,001; 431 [28%] vs 85 [5%] vs 7 [0,2%], p < 0,001, respectivement). Les RCS survenaient également plus rapidement lorsque le rythme initial était un RD (13 minutes [ ±12] vs 18 [ ±13] vs 25 [ ±12], p < 0,001). Cependant, une période de réanimation plus longue était nécessaire afin d'obtenir 95% des RCS préhospitaliers menant à une survie pour les patients avec un RD (26 minutes vs 21 minutes vs 21 minutes). Conclusion: Les patients avec un rythme initial défibrillable suite à leur ACEH sont à meilleur pronostic. Il serait envisageable de transporter plus rapidement vers l'hôpital les patients avec une AESP ou une asystolie que ceux avec un rythme défibrillable si l'arrêt des manœuvres n'est pas envisagé.
LO10: Associations between ED crowding metrics and 72h-hour ED re-visits: Which crowding metrics are most highly associated with patient-oriented adverse outcomes?
Authors: McRae A. , Innes G. , Schull M. , Lang E. , Grafstein E. , Rowe B. , Rosychuk R.
Published: May 2019

Introduction: Emergency Department (ED) crowding is a pervasive problem and is associated with adverse patient outcomes. Yet, there are no widely accepted, universal ED crowding metrics. The objective of this study is to identify ED crowding metrics with the strongest association to the risk of ED revisits within 72 hours, which is a patient-oriented adverse outcome. Methods: Crowding metrics, patient characteristics and outcomes were obtained from administrative data for all ED encounters from 2011-2014 for three adult EDs in Calgary, AB. The data were randomly divided into three partitions for cross-validation, and further divided by CTAS category 1, 2/3 and 4/5. Twenty unique ED crowding metrics were calculated and assigned to each patient seen on each calendar day or shift, to standardize the exposure. Logistic regression models were fitted with 72h ED revisit as the dependent variable, and an individual crowding metric along with a common list of confounders as independent variables. Adjusted odds ratios (OR) for the 72h return visits were obtained for each crowding metric. The strength of associations between 72h revisits and crowding metrics were compared using Akaike's Information Criterion and Akaike weights. Results: This analysis is based on 1,149,939 ED encounters. Across all CTAS groups, INPUT metrics (ED census, ED occupancy, waiting time, EMS offload delay, LWBS%) were only weakly associated with the risk of 72h re-visit. Among THROUGHPUT metrics, ED Length of Stay and MD Care Time had similar adjusted ORs for 72h ED re-visit (range 0.99-1.15). Akaike weights ranging from 0.3/1.00 to 0.4/1.00 indicate that both THROUGHPUT metrics are reasonable predictors of 72h ED re-visits. All OUTPUT metrics (boarding time, # of boarded patients, % of beds occupied by boarded patients, hospital occupancy) had statistically significant ORs for 72h ED re-visits. The median boarding time had the highest adjusted OR for 72h ED re-visit (adjusted OR 1.40, 95% CI 1.33-1.47) and highest Akaike weight (0.97/1.00) compared to all other OUTPUT metrics, indicating that median boarding time had the strongest association with 72h re-visits. Conclusion: ED THROUGHPUT and OUTPUT metrics had consistent associations with 72h ED re-visits, while INPUT metrics had little to no association with 72h re-visits. Median boarding time is the strongest predictor of 72h re-visits, indicating that this may be the most meaningful measure of ED crowding.
LO12: Efficacy of calcitonin for treating acute pain associated with osteoporotic vertebral compression fracture: an updated systematic review and meta-analysis
Authors: Boucher E. , Rosgen B. , Lang E.
Published: May 2019

Introduction: Acutely painful osteoporotic vertebral compression fractures (OVCFs) are common in elderly individuals. Most OVCFs result from falls or routine activities, such as lifting objects or bending. OVCFs are associated with increased hospitalization, mortality and reduced quality of life. Calcitonin has been studied as an alternative or adjunct to opioid or non-opioid analgesia for treating acute pain associated with OVCFs. This review evaluates current evidence on the benefits and harms of calcitonin related to OVCFs. Methods: We registered our review protocol on PROSPERO (CRD42018084850) and conducted our study in compliance with PRISMA guidelines. We searched MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews, clinical trials registries, conference papers and reference lists of included studies. Eligible studies evaluated the effect of calcitonin on pain scores in adults ≥60 years-old with a recent OVCF ( <45 days prior). Two reviewers independently screened studies, extracted data and allocated bias in duplicate. Data were pooled for meta-analysis using standard mean difference (SMD) and a random-effects model. Heterogeneity was evaluated with I2 and sensitivity analyses were performed. The certainty of evidence was assessed with GRADE criteria. Our primary outcome was pain; secondary outcomes include mobility and adverse events. Results: 1180 articles were screened, 11 eligible studies were identified and 9 (627 participants) were pooled for meta-analysis. Pain at rest was lower in the calcitonin group than the control group at week 1 (SMD -1.11, 95% confidence interval (CI) -1.95 to -0.26, I2 = 92%). Sensitivity analysis showed that the route of administration influenced this effect: the SMD for calcitonin nasal spray was -1.88 (95% CI -2.31 to -1.44, I2 = 53%) compared to -0.35 (95% CI -0.86 to 0.17, I2 = 60%) for intramuscular injection. Improvements in mobility were observed at week 4 (SMD -0.48, 95% CI -0.79 to -0.17, I2 = 45%). The risk of adverse events was increased with calcitonin (Risk Ratio 2.72, 95% CI 0.90 to 8.17, I2 = 41%) and consisted of flushing, headache, dizziness and gastrointestinal effects. The overall certainty of evidence was downgraded to low due to concerns over risk of bias and inconsistency between studies. Conclusion: Calcitonin, particularly as a nasal spray, is beneficial and safe for treating acute pain associated with OVCFs. Further studies are needed to improve the certainty of evidence.
LO15: The incidence of intracranial bleeding following a fall on level ground in geriatric patients
Authors: de Wit K. , Merali Z. , Kagoma Y. , Mercier É.
Published: May 2019

Introduction: Falls are a common presentation to the emergency department among geriatric patients. The incidence of intracranial bleeding following a fall is unclear and approach to ordering a CT head scan is not standardized. The aim of this systematic review and meta-analysis was to establish the incidence of intracranial bleeding after a fall in geriatric patients. Methods: The systematic review was registered in PROSPERO. Two authors independently searched Medline and EMBASE (OVID interface) from conception till 20th June 2018. The search combined multiple MESH terms and text words for [falls], [elderly] and [brain injury]. The search was repeated in Google Scholar and recent conference abstracts were reviewed. Studies were included if > 80% of the included patients were > 65 years who presented to the emergency department after a fall on level ground. We excluded studies enrolling select populations (for example trauma team activation, neurosurgical patients or only anticoagulated patients). There were no language restrictions. The random effects model was used to perform a meta-analysis on the incidence of intracranial bleeding in geriatric patients after a fall on level ground. Results: From the 7,043 titles and abstracts, 175 full articles were reviewed and 7 studies, including 6758 patients, were included in the analysis. 2/7 studies were prospective. The studies varied in their inclusion criteria with 3/7 studies only including patients with normal neurological testing. Most retrospective studies included patients if they had a CT head scan. Neither prospective study imaged all patients but both followed the patients for a delayed diagnosis of intracranial bleeding. Risk of bias was moderate or high for the majority of studies. The random effects pooled incidence of intracranial bleeding was 5.2% (95% CI 2.8 – 8.2%), I2 96%. Conclusion: Around 1 in 20 geriatric patients who present to the emergency department after a fall have intracranial bleeding. This point estimate can be used to calculate sample size requirements for future studies on intracranial bleeding in this population.
LO18: The effectiveness of parenteral agents to reduce relapse in patients with acute migraine in emergency settings: a systematic review
Authors: Meyer J. , Visser L. , Kirkland S. , Villa-Roel C. , Junqueira D. , Campbell S. , Rowe B.
Published: May 2019

Introduction: Although a variety of parenteral agents exist for the treatment of acute migraine, relapse after an emergency department (ED) visit is still a common occurrence. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review focused on those studies aiming a reduction in relapse after an ED visit. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to identify comparative studies to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Relapse was reported in 44 (38%) included studies and occurred commonly in patients receiving placebo or no interventions (median = 39%; IQR: 14%, 47%). Overall, no differences in headache relapse were found between patients receiving sumatriptan or placebo (RR = 1.09; 95% CI: 0.55, 2.17; I2 = 93%; n = 8). Conversely, patients receiving neuroleptic agents experienced fewer relapses compared to placebo (RR = 0.27; 95% CI: 0.12, 0.58; I2 = 0%; n = 3); however, patients receiving neuroleptics reported an increase in adverse events (RR = 1.87; 95% CI: 1.17, 3.00; I2 = 0%; n = 3). Compared to placebo, patients receiving dexamethasone were less likely to experience a headache recurrence (RR = 0.71; 95% CI: 0.53, 0.95; I2 = 60%, n = 9); however, no differences were found in reported adverse events (RR = 1.09; 95% CI: 0.81, 1.47; I2 = 0%; n = 3). Conclusion: Relapse is a common occurrence for patients with migraine headaches. This review found patients receiving neuroleptics or dexamethasone experienced fewer headache recurrences. Conversely, triptan agents appear to have minimal effect on reducing the risk for headache recurrence following discharge from an acute care setting. Limited available data on adverse events is an important limitation to inform decision-making. Guidelines should be revised to reflect these results.
LO19: Should emergency physicians bother offering triptans to patients with acute migraine? A systematic review of parenteral agents
Authors: Visser L. , Meyer J. , Kirkland S. , Villa-Roel C. , Junqueira D. , Campbell S. , Rowe B.
Published: May 2019

Introduction: Acute migraine headaches are common causes of presentation to the emergency department (ED). There is great variability in the efficacy of the available parenteral agents to manage pain, though triptans are among the recommended treatments. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review examined pain management in emergency settings and assessed the effectiveness of triptan agents. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Pain scale scores were analyzed using standardized mean difference (SMD) with 95% confidence intervals (CIs) calculated using a random effects model; heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Pain was measured within the ED or equivalent acute care setting using a variety of pain scales, most commonly the 0-10 cm or 100 mm visual analog scale. Four studies compared pain scores between patients receiving sumatriptan vs. other agents, of which, patients receiving sumatriptan reported higher pain scale scores (SMD = 0.53; 95% CI: 0.04, 1.02; I2 = 80%). In particular, patients receiving sumatriptan reported higher pain scale scores than patients receiving metoclopramide (SMD = 0.68; 95% CI: 0.31, 1.04; n = 1) or ketorolac (SMD = 1.39; 95% CI: 0.56, 2.21; n = 1). Overall, studies comparing anti-inflammatory agents (i.e., ketorolac or dexketoprofen) to other agents reported improved pain scale scores among patients receiving anti-inflammatory agents (SMD = -0.38; 95% CI: -0.73, -0.03; I2 = 66%; n = 5). Conclusion: Limited evidence suggests that patients treated with metoclopramide or anti-inflammatory agents experience greater pain reduction compared to patients treated with sumatriptan. This review will conduct a network analysis of parenteral agents to examine the comparative effectiveness of parenteral agents to manage pain among patients with acute migraine. Further analysis will also consider the balance between efficacy and adverse events.
LO23: Identifying patient values and expectations for pulmonary embolism CT scanning in the emergency department
Authors: Swarup V. , Soomro A. , Abdulla S. , de Wit K.
Published: May 2019

Introduction: There is an evidence-practice gap between guidelines for diagnosing pulmonary embolism (PE) and emergency physician practice. Computed tomography (CT) scanning is being overused to exclude PE in Canadian emergency departments (EDs) and current guidelines do not fit well with the ED model of patient care. There is a lack of research on patient opinions on PE testing, and a poor physician understanding of patient-specific goals in the ED. We are addressing this by conducting patient interviews to identify patient-specific values and opinions on PE testing in the ED. These will be used to develop patient-centered educational tools which physicians and patients can use to discuss the decision to order a CT PE scan. The aim of this study is to identify patient expectations and priorities on PE testing in the ED. Methods: This qualitative study uses constructivist grounded theory to analyze patient values and opinions on PE testing in ED patients from two hospitals. Participants are screened by monitoring the ED patient tracker. If a patient is being tested for PE, they are approached and consented by a researcher to take part in a 30-minute semi-structured interview. Each interview is transcribed verbatim and independently analyzed by four researchers using constant comparative coding. The researchers meet weekly to compare codes and agree on common coding terms. The codes are grouped into themes, and the interview script is modified to maximize information on emerging themes. From this, major themes with associated subthemes will be derived, each representing an opportunity, barrier or value which must be addressed in our new patient education tools. We have performed 23 interviews and expect to reach theme saturation at 30 interviews. Full results will be available by the 2019 CAEP conference. Results: From the patient interviews conducted so far, we have mapped four major themes: patient satisfaction comes from addressing their primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination when testing for PE; and patients expect 100% confidence from their ED physician when given a diagnosis. Conclusion: These four domains will be used to create a new patient-centered approach to PE testing in the ED which will include physician education, patient information and organizational changes to patient processing. This study incorporates evidence-based medicine with ethical and social implications to improve patient outcomes.
LO26: Are ED physicians contributing to the opioid epidemic?
Authors: Mok G. , Newton H. , Thurgur L. , Stiell I.
Published: May 2019

Introduction: There is an opioid epidemic which has seen an increased mortality rate of 200% related to opioid use over the past decade. Prescription practices amongst ED physicians may be contributing to this problem. Our objective was to analyze ED physician prescription practices for patients discharged from the ED with acute fractures. Methods: We conducted a health records review of ED patients seen at two campuses of a tertiary care hospital with total annual census of 160,000 visits. We evaluated a consecutive sample of patients with acute fractures (January 1 2016–April 15 2016) seen and discharged by ED physicians. Patients admitted to hospital or discharged by consultant services were excluded. The primary outcome measure was the proportion of patients discharged with an opioid prescription. We collected data using a screening list, review of electronic records, and interobserver agreement for measures. We calculated simple descriptive statistics and estimated 4 months would be required to enroll 250 patients receiving opioid prescriptions. Results: We enrolled 816 patients, with 442 females (54.2%), median CTAS score of 3, and median pain score at triage of 6/10. The most common fractures were wrist/hand (35.2%) and foot excluding ankle (14.8%). An ED pain directive was used at triage for 21.2% and 281 patients (34.4%) received an opioid during ED stay, with tramadol (21.2%) being the most common. Overall, 250 patients (30.6%) were discharged with the following opioid prescriptions and median total dosages: hydromorphone (N = 114, median dosage 23mg, range 1–120mg), tramadol (N = 86, 1000mg, 200–2000mg), oxycodone (N = 33, 100mg, 10–170mg), codeine (N = 20, 600mg, 360–1200mg), and morphine (N = 9, 100mg, 25–200mg). Of patients prescribed hydromorphone, 61 (53.5%) were prescribed > 20mg. Overall, 35 patients (4.3%) had a pain related ED visit <1 month after discharge, of which 14 (40%) received an opioid prescription on initial discharge, and 12 (34.2%) received an opioid prescription upon subsequent discharge. Conclusion: Amongst patients presenting to the ED with acute fractures, the majority were not discharged home with an opioid prescription from ED physicians. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Despite only a minority of patients receiving opioid prescriptions, there were very few return to ED visits. To limit potential abuse, we recommend standardization of opioid prescribing in the ED, with attention to limiting the total dosage given.
LO27: Risk factors for misuse of prescribed opioids: a systematic review and meta-analysis
Authors: Cragg A. , Kitchen S. , Hau J. , Woo S. , Liu C. , Doyle-Waters M. , Hohl C.
Published: May 2019

Introduction: Increasing opioid prescribing has been linked to an epidemic of opioid misuse. Our objective was to synthesize available evidence about patient-, prescriber-, medication-, and system-level risk factors for developing opioid misuse from prescribed opioids among patients presenting with pain unrelated to cancer. Our hypothesis was that we would identify risk factors predisposing patients to developing opioid misuse. Methods: We developed a systematic search strategy and applied it to nine electronic reference databases and six clinical trial registries. We hand searched related journals and conference proceedings, the reference lists of included studies, and the top 100 hits on Google. We included studies where a medical professional exposed adults or children to an opioid through a prescription. We excluded studies with over 50% cancer patients, palliative patients, and those with illicit opioid initiation. Two reviewers independently reviewed titles, abstracts, and full texts, and extracted data using standardized forms. We assessed study quality using risk of bias. We synthesized effect sizes of dichotomous risk factors on opioid misuse using inverse variance random-effects meta-analysis, and the inverse variance-weighted mean difference between opioid misusers and non-misusers for continuously measured factors. We conducted an a priori defined subgroup analysis among opioid-naïve patients. Results: Among 9,629 studies, 67 met our inclusion criteria. Among those who had been prescribed outpatient opioids, the following factors were associated with the development of misuse: a prior history of illicit drug use (OR: 4.21, 95% CI: 2.31-7.65), recent benzodiazepine use (OR: 2.57, 95% CI: 1.23-5.38), any mental health diagnosis (OR: 2.45, 95% CI: 1.91-3.15), any short acting (IR) opioid prescription (OR: 2.40, 95% CI: 1.15-5.02), younger age (OR: 2.19, 95%CI: 1.81-2.64), and male sex (OR: 1.23, 95% CI: 1.10-1.36). Among studies limiting their population to opioid-naïve patients, younger age was the most significant risk factor for opioid misuse (OR: 5.42, 95% CI:1.51-19.43). Conclusion: Of the risk factors examined, non-cancer pain patients with a prior history of substance use or mental health diagnoses were at highest risk for prescription opioid misuse. Younger opioid-naïve patients were at highest risk of misuse. Clinicians should consider these risk factors when managing acute pain in the emergency department.
LO28: Emergency department gastrointestinal presentations related to marijuana ingestion: a single centre retrospective study
Authors: Teefy J. , Blom J. , Woolfrey K. , Riggan M. , Yan J.
Published: May 2019

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a poorly understood phenomenon with a subset of patients presenting to the emergency department (ED) for symptomatic control of refractory nausea and vomiting. As legalization of marijuana commenced on October 2018, it is important to recognize the presentation of patients related to marijuana consumption. The objective of this study was to describe demographic and ED visit data of patients presenting to the ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census 150,000 visits) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations within the ED. Descriptive statistics including means and standard deviations are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Mean (SD) age was 30 (13.04) years and 120 (59.1%) were male. Patients presented to the ED independently 84 (41.4%), via EMS with 104 (51.23%) and 15 (7.39%) by police. The majority of patients were triaged as CTAS-2 in 27 (33%) and CTAS-3 in 106 (52.2%) of all cases. Of patients disclosing their method of consumption, 31 (15.3%) had used combustion methods and 30 (14.8%) had edible marijuana. Mean (SD) serum potassium was 3.71 (0.48) mmol/l. 162 (79.8%) were discharged home and 9 (4.4%) were given follow up (all psychiatric). Twenty-nine (14.3%) were admitted to hospital with 28 (13.8%) admitted to psychiatry and 1 (0.5%) admitted to medicine. Conclusion: This ED-based retrospective chart review reports a description of cannabis-related presentations to the ED. Clinicians should be aware of CHS in patients presenting to the ED, especially as Canada enters the era of legalization. Future research should focus on the impact of federal legalization of marijuana on ED utilization for CHS-related presentations.
LO29: Unexplained variation in ‘to-go’ opioid prescribing across emergency departments in a large Canadian cohort
Authors: Hayward J. , Innes G.
Published: May 2019

Introduction: Emergency Department (ED) opioid prescribing has been linked to long-term use and dependence. Small packets of opioid medications are sometimes prescribed at discharge, i.e. ‘To-Go’, in an attempt to treat pain but avoid unintended consequences. The extent of this practice and its associated risks are not fully understood. This study's objective was to describe the use of ‘To-Go’ opioids in a large urban center. Methods: Multicenter linked administrative databases were used to recruit an observational cohort. The referral population was comprised of all patients discharged from a Calgary ED in 2016 (four hospitals) with an arrival pain score greater than 0. We first described this population and then performed a multivariable analysis to assess for predictors of ‘To-Go’ opioids. ‘To-Go’ opioids were either Tylenol-Codeine or Tylenol-Oxycodone. Results: A total of 88,855 patients were recruited. The majority were female (57%) and the average age was 44.5 yrs. Abdominal pain was the most frequent complaint (22.1%) followed by extremity (18.3%) and cardiac pain (8.0%). Overall, 2,736 patients (3.1%) received an opioid ‘To-Go’ with significant variation in prescribing rates across hospitals (1.8-5% Chi2 p < 0.05). Logistic regression (covariates: age, sex, CTAS, pain score, type of pain, hospital, ED opioid, length of stay) revealed that receiving an opioid (IV or PO) prior to discharge was the strongest predictor of ‘To-Go’ opioid (OR 6.4 [5.9-7.0]). Hospital (OR 1.4 [1.3-1.4]) and male sex (OR 1.2 [1.1-1.3]) also emerged as predictors, whereas age over 65 decreased the odds of ‘To-Go’ opioid (OR 0.8 [0.6-0.9]). Hospital-specific ORs ranged from 1.3-2.7. Conclusion: In comparable patient populations some hospitals are more likely than others to provide a short course of opioids at discharge. This difference is not explained by patient demographics, pain profiles, or medications prior to discharge. The reasons for this variation are unclear but it underscores the need to determine the risks of ED opioid exposures and develop clear evidence-based prescribing guidelines.
LO34: Predictors of intravenous rehydration in children with acute gastroenteritis in the United States and Canada
Authors: Poonai N. , Powell E. , Schnadower D. , Casper T. , Roskind C. , Olsen C. , Tarr P. , Mahajan P. , Rogers A. , Schuh S. , Hurley K. , Gouin S. , Vance C. , Farion K. , Sapien R. , O'Connell K. , Levine A. , Bhatt S. , Freedman S. ,   on behalf of Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN)
Published: May 2019

Introduction: Although oral rehydration therapy is recommended for children with acute gastroenteritis (AGE) with none to some dehydration, intravenous (IV) rehydration is still commonly administered to these children in high-income countries. IV rehydration is associated with pain, anxiety, and emergency department (ED) revisits in children with AGE. A better understanding of the factors associated with IV rehydration is needed to inform knowledge translation strategies. Methods: This was a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) randomized, controlled trials of oral probiotics in children with AGE-associated diarrhea. Eligible children were aged 3-48 months and reported > 3 watery stools in a 24-hour period. The primary outcome was administration of IV rehydration at the index ED visit. We used mixed-effects logistic regression model to explore univariable and multivariable relationships between IV rehydration and a priori risk factors. Results: From the parent study sample of 1848 participants, 1846 had data available for analysis: mean (SD) age of 19.1 ± 11.4 months, 45.4% females. 70.2% (1292/1840) vomited within 24 hours of the index ED visit and 34.1% (629/1846) received ondansetron in the ED. 13.0% (240/1846) were administered IV rehydration at the index ED visit, and 3.6% (67/1842) were hospitalized. Multivariable predictors of IV rehydration were Clinical Dehydration Scale (CDS) score [compared to none: mild to moderate (OR: 8.1, CI: 5.5-11.8); severe (OR: 45.9, 95% CI: 20.1-104.7), P < 0.001], ondansetron in the ED (OR: 1.8, CI: 1.2-2.6, P = 0.003), previous healthcare visit for the same illness [compared to no prior visit: prior visit with no IV (OR: 1.9, 95% CI: 1.3-2.9); prior visit with IV (OR: 10.5, 95% CI: 3.2-34.8), P < 0.001], and country [compared to Canada: US (OR: 4.1, CI: 2.3-7.4, P < 0.001]. Significantly more participants returned to the ED with symptoms of AGE within 3 days if IV fluids were administered at the index visit [30/224 (13.4%) versus 88/1453 (6.1%), P < 0.001]. Conclusion: Higher CDS scores, antiemetic use, previous healthcare visits and country were independent predictors of IV rehydration which was also associated with increased ED revisits. Knowledge translation focused on optimizing the use of antiemetics (i.e. for those with dehydration) and reducing the geographic variation in IV rehydration use may improve the ED experience and reduce ED-revisits.
LO37: Prevalence of cigarette smoking amongst adult emergency department patients
Authors: Tolmie A. , Erker R. , Oyedokun T. , Sullivan E. , Graham T. , Stempien J.
Published: May 2019

Introduction: Tobacco smoking is a priority public health concern, and a leading cause of death and disability globally. While the smoking prevalence in Canada is approximately 13-18%, the proportion of smokers among emergency department (ED) patients has been found to be significantly higher. This disparity primes the emergency department as a critical environment to provide smoking cessation counselling and support. Methods: A verbal questionnaire was administered to adult patients (18+) presenting to Royal University, Saskatoon City, and St. Paul's Hospital ED's. Patients were excluded if they were underage, too ill, or physically/mentally unable to complete the questionnaire independently. Patients’ smoking habits were also correlated with Fagerstrom tobacco dependence scores, chief complaints, Canadian Triage Acuity Scale (CTAS) scores, and willingness to partake in ED specific cessation counselling. Data were analyzed using IBM SPSS software to determine smoking prevalence and compared to Statistics Canada data using chi-square tests. Results: In total, 1190 eligible patients were approached, and 1078 completed the questionnaire. Adult Saskatoon ED patients demonstrated a cigarette smoking prevalence of 19.6%, which is significantly higher than the general adult Saskatchewan public at 15.1% (p < 0.0001). Comparing smoking and non-smoking cohorts, there are no significant differences in CTAS scores (p = 0.60). Of the proposed cessation interventions, ED cessation counselling was most popular among patients (62.4%), followed by receiving a pamphlet (56.2%), and being contacted by a smokers’ quit line (49.5%). Out of the smoking cohort, 51.4% indicated they want to quit smoking, and would be willing to partake in ED-specific cessation counselling, if available. Additionally, 88.1% of current smokers started smoking when they were less than 19 years old. Conclusion: The higher smoking prevalence demonstrated in ED patients highlights the need for a targeted intervention program that is feasible for the fast-paced environment. Quit attempts have been demonstrated to be more efficacious with repeated interventions, which could be achieved by training ED staff to conduct brief motivational interviews and faxing referrals to a smokers' quit line for follow-up. Furthermore, pediatric ED's could be a valuable location for cigarette smoking screening, as the majority began smoking in their adolescence.
LO40: Services for emergency department patients experiencing early pregnancy complications: a survey of Ontario hospitals
Authors: Glicksman R. , McLeod S. , Thomas J. , Varner C.
Published: May 2019

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. These hospitals constitute greater than 85% of the annual ED visits in Ontario, creating a sample reflective of the services available to most women older than 18 years old seeking care for early pregnancy complications in the province. Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications including pregnancy of unknown location and threatened abortion. Respondents also stated that radiologist-interpreted ultrasound was only available to 22 (34.9%) of hospital sites 24 hours a day, 7 days per week for women with early pregnancy complications. Of hospital site respondents, 55 (87.3%) reported point-of-care ultrasound (POCUS) use in the ED for patients with early pregnancy complications, and 27 (49.1%) reported the ED had access to transvaginal ultrasound probes for POCUS assessment by emergency physicians. Additionally, the proportion of ED physicians who were certified as Canadian Emergency Ultrasound independent practitioners ranged from 10% to 100%. Conclusion: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.
LO41: Evaluating paramedic comfort, confidence, and cultural competency in providing care to trans populations in a provincial ambulance system
Authors: Kengis L. , Goldstein J. , Urquhart R. , McIver K.
Published: May 2019

Introduction: Close to 2 million transgender (trans) individuals live in the United States and Canada. Trans communities frequently report emergency care avoidance and negative health care experiences. Of note, there is currently no research on the paramedic perspective of caring for trans populations. Our objective was to explore paramedic comfort, confidence, and cultural competency in providing emergency care to trans individuals. Methods: A cross-sectional, semi-structured electronic survey was administered by email to paramedics registered with the College of Paramedics of Nova Scotia (n = 1225) from April 9th to May 7th, 2018. The survey included previously validated questions from other medical settings. Three survey reminders were sent at weekly intervals following survey initiation. A 4-point Likert scale and qualitative open-ended questions were included to evaluate paramedic comfort, confidence, and cultural competency. Descriptive statistics were used to describe respondent characteristics. Open ended questions pertaining to paramedic needs were evaluated using constant comparative analyses consisting of open coding to identify themes. Results: Of the 387 paramedics who participated (response rate = 32%), 77.8% (n = 301) worked ground ambulance in a mixed rural/urban location (32.6%, n = 126) within Nova Scotia (94.5%; n = 365). Most respondents were between the ages of 41-50 (29.5%; n = 114), with > 20 years’ experience (25.1%; n = 97), and male sex assigned at birth (56.1%; n = 217). Over half (54.8%; n = 212) identified as cisgender men. The majority (66.1%; n = 256) reported caring for a patient who identified as trans. 74.7% (n = 289) have never had formal education on trans health. Only 4.1% (n = 16) felt very knowledgeable about providing optimal care to trans communities and 26.6% (n = 103) felt very comfortable in providing optimal care. Most (70%; n = 271) were interested in obtaining formal education. 41.9% (n = 162) reported observing transphobia in the work place. Conclusion: The frequency of trans patient contact by paramedics is perceived to be high. Although comfort and knowledge are relatively low and transphobia witnessed in the work place relatively high, there was strong interest and expressed need for education on trans related health.