bluuebunny/crossref_metadata_2025 huggingface dataset:
P010: Emergency department performed renal point-of-care ultrasound (POCUS) for the assessment of obstructive uropathy: Impact of a training curriculum and ongoing educational intervention
Authors: Bastien D. , Thompson D. , Myslik F. , Van Aarsen K. , Serhan J. , Hassani B.
Published: May 2019

Introduction: Hydronephrosis is the de facto measure of obstructive uropathy (OU) and can be evaluated using renal Point of Care Ultrasound (rPOCUS). This educational initiative aimed to develop an effective one-day rPOCUS curriculum and evaluate if feedback/quality assurance (QA), leads to an improvement in image acquisition and interpretation of hydronephrosis as well as comfort with the technique. Methods: Physicians were randomized into a QA or control group (NQA) and all attended a one day training session which involved acquiring rPOCUS scans with one-on-one instruction. Participants then performed POCUS scans on all ED patients where formal renal US was deemed clinically indicated. The QA group received feedback on every scan from qualified ED physicians. Overall sensitivity and specificity were calculated compared to formal scans using a chi-square test. Written QA was reviewed for future improvements. Crossover occurred at 10 weeks to allow for equal learning opportunity but analyses focused on pre-crossover data. Participants completed surveys at study start and end focusing on initiative effectiveness and barriers/comfort with POCUS measured with a likert scale (Not at all (1)-Very (7)). Results: Fourteen ED physicians participated. The most common cited barrier to utilizing rPOCUS was lack of knowledge/training (78.6%). A total of 63 POCUS scans were reviewed. Common feedback included breath-holding (69.7%), use of color doppler (48.5%) and including a transverse sweep (36.4%). Sensitivity and specificity were better in the QA versus NQA group though the difference was not significant (Se- 75.0% vs 50.0%, 95%CI: −34.0-73.4%; Sp- 89.3% vs 73.9%, 95% CI: 8.2-39.2%). Ten physicians completed the post survey; all reported improved comfort with rPOCUS in assessment of hydronephrosis (median [IQR]: Δ+2 [1-3]). At study end, the comfort rating for using only POCUS and not formal scan remained low (median [IQR]: 3.50 [1.8-4.2]). The training initiative was rated highly with a median [IQR] rating of 5.50 [4.8-7.0]. Conclusion: Although the initiative was rated highly effective and resulted in improved comfort with renal POCUS, physicians did not feel comfortable solely using POCUS without formal scan to diagnose OU. Despite the initiative's success, further educational programs are needed before rPOCUS can be safely used as the primary investigation. In the future, a greater emphasis should be placed on the commonly noted areas of improvement.
P011: A pre-clerkship procedural curriculum designed for the future of Canadian medical education: a pilot and feasibility study
Authors: Battaglia F. , Merlano M. , Sayed C. , McConnell M. , Ramnanan C. , Rastogi N.
Published: May 2019

Introduction: Procedural skills training varies significantly across Canadian medical schools, and there is currently no standardized assessment tool to evaluate its benefits. This project aims to develop a curriculum that teaches 2nd-year medical students to perform and evaluate procedural skills. The goals of this program include decreasing anxiety, increasing confidence, and achieving competence for students and also allowing staff to judge the appropriate level of supervision when delegating learners to perform basic procedures in the team setting. Our curriculum incorporates, near-peer teaching as well as near peer formative assessment. Methods: Each of the twelve 2nd year participants completed a State Trait Anxiety Inventory and self-reported confidence questionnaire related to procedural skills. Students participated in four sessions taught by expert physicians over a five month period. A new skill was taught at each monthly workshop and an opportunity to practice previously taught skills was provided. Skills were assessed in a skills integration simulation OSCE, and the anxiety and confidence questionnaire was repeated. Results: Students who completed this pilot program showed a significant decrease in mean anxiety state (2.48 vs 1.74, p-value <0.001), while the control group did not (p-value = 0.408). When assessing confidence, students who completed this program showed increased self-assessed knowledge and confidence in each of the program's assessed skills. An increased level of competency was achieved in each skill by each student as assessed by the expert physicians. Conclusion: There is evidence to suggest that implementation of this procedural skills training model within the Canadian medical school curriculum may improve student anxiety, confidence, and competency for success in clerkship and could be the foundation for developing milestones for EPAs.
P024: Obtaining consensus on optimal management and follow-up of patients presenting to the emergency department with early pregnancy complications – a modified Delphi study
Authors: Cornelis A. , Clouston R. , Atkinson P.
Published: May 2019

Introduction: Complications in early pregnancy are common and have many physical and emotional consequences. Locally, there is no early pregnancy loss clinic or standardized guide in the emergency department (ED) for referral and follow-up decisions, and both initial management of patients and follow up can be inconsistent. This study aimed to obtain consensus on the best approach to initial work-up, management, and follow up for patients who present to the ED with early pregnancy complications, with the goal of using this consensus to produce a standardized guide for emergency provider use. Methods: A literature review was completed to produce evidence-based recommendations which were used to initiate a modified Delphi consensus process. A survey was distributed, with three rounds completed. Participants included emergency providers, obstetrician-gynecologists, a radiologist, a sample of family medicine physicians including some involved in primary care obstetrics, and nurse practitioners. An obstetric specialist from outside the local region was also involved. Results: Consensus was reached on several key recommendations, however some areas remained without clear accepted best practice. There was consensus that physical components of early pregnancy complications are addressed well, but that we could improve on patient flow and more consistent follow up. Important investigations to be done for patients were identified. The timing of formal ultrasound, necessity and timing of obstetrician consultation, and safety of discharge was addressed for various patient scenarios including stable and unstable patients, with and without adnexal pain, with intrauterine pregnancy of uncertain viability, and with pregnancy of unknown location. Management of confirmed early pregnancy loss in the ED and family medicine clinics was addressed. Barriers to an early pregnancy loss clinic included lack of funding, space, and staffing as well as lack of resources and uncertain patient volumes. A feasible alternative to an early pregnancy loss clinic was for willing providers to keep appointment times available to facilitate confirmation of follow-up prior to discharge. Other suggested alternatives included an early pregnancy loss clinic, a nurse educator, and having a standardized guideline in the ED. Conclusion: Through a consensus approach, several recommendations were agreed upon for improving care for patients presenting to the ED with early pregnancy complications.
P031: Naltrexone initiation for alcohol use disorder in the emergency department: A systematic review
Authors: Deschner E. , Walsh C. , Spithoff S. , McLeod S. , Borgundvaag B. , Bearss E. , Foote J. , Gravel J.
Published: May 2019

Introduction: Alcohol use disorder (AUD) is a chronic relapsing and highly comorbid disease. Patients suffering from AUD are frequently seen in the emergency department (ED) presenting intoxicated or in withdrawal. Brief interactions in the ED are often the only portal of entry to the healthcare system for many of these patients. Oral naltrexone and long acting injectable naltrexone are effective treatment options for AUD associated with decreased cravings, shorter length of hospital stay, and lower cost of healthcare utilization. This study's objective was to perform a systematic review of the literature evaluating initiation of naltrexone in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing initiation of naltrexone in patients (≥18 years) to standard care in the ED were included. Two reviewers independently screened titles and abstracts, reviewed full text articles for inclusion, assessed quality of the studies, and extracted data. Results: The search strategy yielded 183 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 10 articles were retrieved for full text review. There were no published RCTs that examined naltrexone initiation in the ED. There is one ongoing study being conducted in New York, which aims to assess naltrexone initiation in the ED and measure health outcomes and quality of life of study participants, as well as potential healthcare cost savings. Conclusion: The lack of published research in this area demonstrates a significant gap in knowledge. It is clear that well-designed RCTs are needed to evaluate the effectiveness of initiating naltrexone for those with AUD at the ED visit.
P038: A procedural skills needs assessment targeting physicians providing emergency department coverage in rural Newfoundland and Labrador
Authors: Dunne C. , Parsons M.
Published: May 2019

Introduction: Maintaining competence in high-acuity low-occurrence (HALO) procedures is often difficult due to their infrequent occurrence. While simulation is a valuable tool to hone skills, providing effective simulation-based education (SBE) to learners outside academic centers can be challenging. Utilizing a mobile tele-simulation unit (MTU) with expert instruction from a geographically separated mentor could prove a valuable approach to overcoming barriers in this setting. However, to maximize benefit and buy-in, the training modules developed for this unique delivery method must align with the needs of those practicing in rural settings. Objectives: - To evaluate the procedural skills training needs of emergency medicine (EM) physicians in rural Newfoundland and Labrador (NL) - To inform the development of simulation modules designed for use in a MTU Methods: A web-based needs assessment was distributed to physicians registered with the NL Medical Association, working in rural locations, and having EM listed as their primary specialty. Participants evaluated their comfort, performance frequency and desire to have further training for 12 HALO procedures. Two EM physicians selected these from a broader list of core procedural skill competencies for CCFP-EM residents at Memorial University. Participants were also able to suggest other procedures that might benefit from SBE. Results: The data collection occurred for 8 weeks with a 68% response rate (N = 22). No respondents had formal EM training outside of exposure in family medicine residency. 60% had 10+ years practicing EM. Chest tube insertion (100%), difficult intubation (92.3%) and surgical airway (92.3%) were the procedures that most respondents felt required more SBE. In practice, they most often performed bag-valve ventilation, splint application and procedural sedation (>10 per year). Additional procedures felt to require SBE were central venous line placement and trauma assessment. Opportunities to participate in SBE were limited (66.7%-less than annually). Despite this, most participants agreed SBE would be a significant benefit if accessible (93.3%). The greatest barriers to SBE included lack of equipment, rural location, and time necessary for travel to larger centres. Conclusion: The provision of medical care in rural settings can be particularly challenging when HALO procedures must be performed. Unique delivery methods of SBE targeted to the needs of rural practitioners may help bridge gaps in knowledge and technical skills.
P041: Does the involvement of learners in emergency department patient assessments result in an increased rate of short-term return visits?
Authors: Elliott C. , Chen K. , Fitzpatrick T.
Published: May 2019

Introduction: Learners, ether medical students or residents, often provide the initial assessment of patients visiting the Emergency Department (ED). Their involvement in ED patient care has been shown to increase length of stay, time to disposition decision, utilization of imaging and admission rates. It is unclear, however, if learners have an impact on the rate of short-term unscheduled return visits. The objective of this study was to determine if the involvement of learners in ED visits increases the rate of short-term unscheduled return visits. Methods: This study was a retrospective analysis of ED visit data at a single tertiary care center over a one-year period. Short-term unscheduled return visits (return visits) were defined as ED visits presenting within 72 hours of discharge from an initial non-admit ED visit and resulting in an admission to an inpatient unit on the second visit. The primary outcome was the rate of return visits for each staff physician, with and without learners involved during the initial visit. The secondary outcome assessed the interaction of level of training (medical student year 3, 4, resident year 1, 2, etc.) on return visit rates. For the primary outcome, statistical analysis was with a Wilcoxon Matched Pairs test; staff alone vs with learners. A Kruskal-Wallis test was used to compare learner level of training. Results: Return visits accounted for 1858 (1.09%) of all visits (N = 172494) to this tertiary care ED over the one-year study period. Return visits were statistically more likely when learners were involved in the initial ED visit (1.16%, CI 0.12), compared to initial visits seen by staff physicians alone (0.88%, CI 0.09) (p < 0.0001). Return rates were statistically higher for PGY2 (1.67% CI 0.35) and PGY3 (1.66% CI 0.28) residents compared to staff physicians alone (p < 0.0001). There was no difference in return visit rates between staff physicians and third year medical students (1.07% CI 0.27), fourth year medical students (1.21% CI 0.37), PGY1 (1.42% CI 0.22), PGY4 (1.23% CI 0.54) or PGY5 (1.33% CI 0.49) residents. Conclusion: This study demonstrated that the involvement of learners in ED patient assessments increased the rate of short-term unscheduled return visits. Moreover, return visit rates were highest for PGY2 and PGY3 residents. Further work is needed to understand the factors that contribute to this phenomenon.
P047: Understanding the expert approach to managing frailty in the emergency department
Authors: Forrester S. , Nelson M. , McLeod S. , Melady D.
Published: May 2019

Introduction: Frailty is a state of vulnerability affecting older adults, and has been associated with adverse events such as increased risk of institutionalization, falls, functional decline, and mortality. Previous research suggests that emergency department (ED) physicians are much less comfortable managing the complex care needs of frail, older adults. The objective of this study was to identify successful strategies and expert skills that ED physicians possess to optimally manage the frail, older patient. Methods: An interpretive descriptive qualitative study was conducted. One of the investigators contacted the site leads of 12 academic and community EDs across Canada to identify ED physicians who they perceived as being highly skilled in the care of frail, older patients. 22 individual physicians were identified and 13 physicians representing 10 EDs were invited to participate in a 30-minute semi-structured interview. Transcripts were coded by two members of the research team. Data collection is ongoing and analyses will occur until thematic saturation. Results: All participants indicated they were very comfortable managing the frail, older patient in the ED. Awareness of issues related to this patient population were triggered by both clinical and personal experiences, as well as institutional priorities. When asked how they developed their specific skills for this patient population, participants stated they received limited formal training during residency and early practise, but relied on situational learning, access to role models and engagement in self-directed learning. Participants identified three predominant management strategies for the care of the frail, older patient: thorough patient interaction at the start of the clinical encounter to maximize efficiency; engaging in teamwork to manage complex issues; and early involvement of the family/caregivers. Interestingly, not all participants used the term frailty, however most reflected principles of the concept in their discussion. Conclusion: Currently, principles of caring for frail, older adults are not widespread in emergency medicine residency training. These findings suggest that frailty care frequently requires an alternative clinical approach, which is often derived from personal experience, self-directed and experiential learning. Future educational initiatives should derive, implement and evaluate a wide-spread curriculum to teach the skills required to optimally care for these patients.
P049: Post-intubation sedation in the emergency department: a survey of national practice patterns
Authors: Freeman S. , Columbus M. , Nguyen T. , Mal S. , Yan J.
Published: May 2019

Introduction: Endotracheal intubation (ETI) is a lifesaving procedure commonly performed by emergency department (ED) physicians that may lead to patient discomfort or adverse events (e.g., unintended extubation) if sedation is inadequate. No ED-based sedation guidelines currently exist, so individual practice varies widely. This study's objective was to describe the self-reported post-ETI sedation practice of Canadian adult ED physicians. Methods: An anonymous, cross-sectional, web-based survey featuring 7 common ED scenarios requiring ETI was distributed to adult ED physician members of the Canadian Association of Emergency Physicians (CAEP). Scenarios included post-cardiac arrest, hypercapnic and hypoxic respiratory failure, status epilepticus, polytrauma, traumatic brain injury, and toxicology. Participants indicated first and second choice of sedative medication following ETI, as well as bolus vs. infusion administration in each scenario. Data was presented by descriptive statistics. Results: 207 (response rate 16.8%) ED physicians responded to the survey. Emergency medicine training of respondents included CCFP-EM (47.0%), FRCPC (35.8%), and CCFP (13.9%). 51.0% of respondents work primarily in academic/teaching hospitals and 40.4% work in community teaching hospitals. On average, responding physicians report providing care for 4.9 ± 6.8 (mean ± SD) intubated adult patients per month for varying durations (39.2% for 1–2 hours, 27.8% for 2–4 hours, and 22.7% for ≤1 hour). Combining all clinical scenarios, propofol was the most frequently used medication for post-ETI sedation (38.0% of all responses) and was the most frequently used agent except for the post-cardiac arrest, polytrauma, and hypercapnic respiratory failure scenarios. Ketamine was used second most frequently (28.2%), with midazolam being third most common (14.5%). Post-ETI sedation was provided by > 98% of physicians in all situations except the post-cardiac arrest (26.1% indicating no sedation) and toxicology (15.5% indicating no sedation) scenarios. Sedation was provided by infusion in 74.6% of cases and bolus in 25.4%. Conclusion: Significant practice variability with respect to post-ETI sedation exists amongst Canadian emergency physicians. Future quality improvement studies should examine sedation provided in real clinical scenarios with a goal of establishing best sedation practices to improve patient safety and quality of care.
P052: Breaking down the pieces: A scoping review exploring the components of image ordering interventions and trends in their outcomes in pediatric emergency medicine
Authors: Gaudet L. , Krebs L. , Carr M. , Kruhlak M. , Hall A. , Mahoney K. , Sevcik B. , Rowe B.
Published: May 2019

Introduction: Clinicians treating children in the emergency department (ED) are especially concerned with the efficacy and safety of imaging. Interventions to limit imaging have been proposed to maximize benefits and avoid risks; however, the types and effectiveness of interventions employed in pediatric EDs have not been examined in detail. Methods: Electronic databases and grey literature were systematically searched by a medical librarian. Comparative studies of ED-based interventions reporting computed tomography (CT), radiography (XR), or ultrasound (US) outcomes were included. Interventions introducing new imaging equipment or personnel to the ED, ED diversion strategies, and pre-admission protocols were excluded. At least two independent reviewers assessed each study for inclusion based on pre-defined criteria and extracted data. Disagreements were resolved through consensus. Descriptive results are reported. Results: Overall, 38 pediatric studies were included. Most (66%) interventions implemented two or more components; the most common intervention components were clinical guidelines or pathways (87%) and education or information (66%). Studies were categorized by presentation type: traumatic (n = 27); non-traumatic (n = 19), or combined ‘all-comers’ (n = 2). Included studies reported 62 imaging outcomes (CT = 29; XR = 20; US = 13). Among traumatic studies, 26 imaging outcomes were reported; CT was the most commonly reported outcome (CT = 15; XR = 9; US = 1). Of the CT outcomes, 33% reported significant decreases and five decreased but were either not significant or did not report significance. XR significantly decreased in 44% (4/9). In the non-traumatic studies, the most common imaging outcome remained CT (12 outcomes); 58% of which reported significant decreases. XR was the second most frequent outcome, with 63% reporting significant reductions. Combined success of the interventions to reduce CT and XR was 60%. Reported changes in ordering were less consistent in US. Conclusion: Multifaceted passive interventions have been implemented to reduce imaging in pediatric EDs. Most reported some success changing ordering practices, specifically among patients with non-trauma presentations. Future research exploring relationships between intervention content, effectiveness, and fidelity may provide insight into how to develop more effective interventions to change image ordering in the ED and guide which presentations to target.
P054: The effectiveness of emergency department-based interventions for patients with advanced or end-stage illness: a systematic review
Authors: Ghalab A. , Kruhlak M. , Kirkland S. , Ruske H. , Campbell S. , Villa-Roel C. , Rowe B.
Published: May 2019

Introduction: Patients with advanced or end-stage illness frequently present to emergency departments (EDs), many of whom are in need of palliative care (PC). Emergency physicians have struggled in providing high quality care to these patients and there is a need to identify cost-effective PC interventions delivered in the ED to improve patient outcomes. The objective of this systematic review was to examine the effectiveness of ED-based PC interventions. Methods: A comprehensive search of nine electronic databases and grey literature sources was conducted to identify any comparative studies assessing the effectiveness of ED-based PC interventions to improve health outcomes of patients with advanced or end-stage illness. Two independent reviewers completed study selection, quality assessment, and data extraction. Differences were mediated via third-party adjudication. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: From 5882 potentially eligible citations, 12 studies were included. Two studies are currently on-going clinical trials, and as such, 10 studies were included in this analysis. The studies consisted of before-after studies (n = 5), RCTs (n = 4), and an observational cohort (n = 1). Interventions assessed among the included studies consisted primarily of ED-directed PC consultations (n = 6), while other studies assessed screening of patients with advanced or end-stage illness and PC needs (n = 2), education on PC for ED-staff (n = 1), and an ED-based critical care unit (n = 1). Infrequent reporting of important outcomes (e.g., Mortality, ED relapse) limited the ability of this review to conduct meaningful meta-analysis. There was no difference in patient mortality between two studies assessing ED-directed PC consultations (RR = 0.89; 95% CI: 0.71, 1.13; I2 = 0%). One before-after study (RR = 0.73; 95% CI: 0.47, 1.13) and two RCTs (RR = 2.19; 95% CI: 0.40, 11.92; I2 = 96%) did not identify significant differences in PC consultations intervention (implementation of ED-directed PC consultations) and control (usual care) patients. Conclusion: This review found limited evidence to support the recommendation of any particular ED-based intervention for patients presenting to the ED with advanced or end-stage illness. High quality studies and standardized outcome reporting are needed to better understand the impact of PC interventions in the ED setting.
P058: Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: a retrospective cohort study
Authors: Coles J. , Erdogan M. , Higgins S. , Green R.
Published: May 2019

Introduction: Long-term immobility has detrimental effects for critically ill patients admitted to the intensive care unit (ICU) including ICU-acquired weakness. Early mobilization of patients admitted to ICU has been demonstrated to be a safe, feasible and effective strategy to improve patient outcomes. The optimal mobilization of trauma ICU patients has not been extensively studied. Our objective was to determine the impact of an early mobilization protocol on outcomes among trauma patients admitted to the ICU. Methods: We analyzed all adult trauma patients ( > 18 years old) admitted to ICU over a 2-year period prior to and following implementation of an early mobilization protocol, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared patient characteristics and outcomes (mortality, length of stay [LOS], ventilator days) between the pre- and post-implementation groups. Associations between early mobilization and clinical outcomes were estimated using binary and linear regression models. Results: Overall, there were 526 patients included in the analysis (292 pre-implementation, 234 post-implementation). The study population ranged in age from 18 to 92 years (mean age 49.0 ± 20.4 years) and 74.3% of all patients were male. The pre- and post-implementation groups were similar in age, sex, and injury severity. In-hospital mortality was reduced in the post-implementation group (25.3% vs. 17.5%; p = 0.031). In addition, there was a reduction in ICU mortality in the post-implementation group (21.6% vs. 12.8%; p = 0.009). We did not observe any difference in overall hospital LOS, ICU LOS, or ventilator days between the two groups. Compared to the pre-implementation period, trauma patients admitted to the ICU following protocol implementation were less likely to die in-hospital (OR = 0.52, 95% CI 0.30-0.91; p = 0.021) or in the ICU (OR = 0.40, 95% CI 0.21- 0.76, p = 0.005). Results were similar following a sensitivity analysis limited to patients with blunt or penetrating injuries. There was no difference between the pre- and post-implementation groups with respect to in-hospital LOS, ICU LOS, or the number of ventilator days. Conclusion: We found that trauma patients admitted to ICU during the post-implementation period had decreased odds of in-hospital mortality and ICU mortality. Ours is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.
P066: Ultrasound localization to resuscitate in arrest (ULTRA)
Authors: Olszynski P. , Woods R. , Netherton S. , Hussain Q. , Blondeau B. , Dunn S.
Published: May 2019

Introduction: There is increasing evidence supporting ultrasonography for the determination of optimal chest compression location during cardiac arrest. Radiological studies have demonstrated that in up to 1/3 of patients the aortic root or outflow tract is being compressed during standard CPR. Out-of-hospital-cardiac-arrests (OHCA) could benefit from cardiac localization, undertaken with scaled-down ultrasound equipment by which the largest fluid filled structure in the chest (the heart) is identified to guide optimal compression location. We intend to evaluate 1) where the left ventricle is in supine patients, 2) the accuracy and precision as well as 3) the feasibility and reliability of cardiac localization with a scaled down ultrasound device (bladder scanners). Methods: We are recruiting men and women over the age of 40. The scanning protocol involves using a bladder scanner on a 15-point grid over the subject's left chest and parasternal, midclavicular, and anterior axillary intercostal spaces 3-7. Detected volumes will be recorded, with the presumption that the intercostal space with the largest measured volume is centered over the heart. Echocardiography will then be used to confirm the bladder scanner accuracy and to better describe the patient's internal chest anatomy. Having assessed procedural feasibility on 3 pilot subjects, we are now recruiting 100 participants, with planned interim analysis at 50 participants for sample size reassessment. Maximal volume location frequencies from the echocardiograms will be described and assessed for variation utilizing the goodness-of-fit test. The proportion of agreement across the two modalities regarding the maximal volume location will also be examined. Results: Among the 3 volunteers (pilot study), the scanner identified fluid in 4-8 of 15 intercostal spaces. In each of the three pilot study patients, the maximal volume identified by the bladder scanner was found to be at the parasternal location of the 6th intercostal space. This was also the location of the mid left ventricular diameter on echocardiography. Conclusion: Our literature review and pilot study data support the premise that lay persons and emergency medical personnel may improve compressions (and thus outcomes) during OHCA by using a scaled-down ultrasound to identify the location of optimal compression. We are currently enrolling patients in our study.
P069: Does specialist referral influence emergency department return rate for patients with renal colic? A retrospective cohort study
Authors: Kanji A. , Atkinson P. , Massaro P. , Pawsey R. , Whelan T.
Published: May 2019

Introduction: Renal colic is a common presentation which exerts a significant burden on healthcare infrastructure. A significant proportion of patients managed with observation may return to the Emergency Department (ED) prior to spontaneous passage due to inadequate analgesia. It is unclear whether early urologist consultation would limit the burden of renal stones by reducing returns to the ED. We wished to determine whether urologist referral from the ED department is associated with fewer returns to the ED with renal colic. Methods: We conducted a retrospective chart review using RECORD methodology of consecutive patients diagnosed with CT-confirmed, ureteric or renal calculi in our ED over a two-year period. Disposition was categorized as either hospital admission, outpatient urologist referral, follow up with primary care, or no follow up. The primary outcome was the 30-day ED re-presentation for renal colic. Multivariate logistic regression was used to identify predictors for ED-return. Results: In total, 232 patients met our inclusion criteria. Urgent or outpatient urologist referral was not associated with a significantly lower ED return rate when compared to patients with no follow-up. Surprisingly, urologic intervention and stent placement were both independent predictors for ED return (OR: 2.03; 95% CI: (1.06-3.88); p:0.03) and (OR:2.08; 95% CI: (1.07-4.05). Conclusion: A significant proportion of patients who underwent urologist-led intervention returned to the ED with renal colic. Further study may help clarify the role of early urologist referral for renal calculi, as this may not reduce ED return rates when compared to conservative management.
P076: Do QR codes effectively engage patients in research while visiting the emergency department?
Authors: Krebs L. , Villa-Roel C. , Ushko D. , Sandhar G. , Ruske H. , Couperthwaite S. , Holroyd B. , Ospina M. , Rowe B.
Published: May 2019

Introduction: Efforts to engage patients in research when presenting to emergency departments (EDs) have explored the utility of online tools; for example, through QR-based applications. It is unclear whether these are effective strategies for engaging patients in research activities while saving costs of in-person surveys. This study evaluated whether patients would participate in QR codes or short URL-linked surveys available in EDs across Alberta. Methods: A patient waiting room poster was developed as part of a stepped-wedge randomized controlled trial. The waiting room poster was introduced in 15 urban and regional Alberta EDs with a median annual volume of approximately 60,000. A QR-code and short URL were placed on the poster inviting patients to participate in an online survey and evaluate the poster's usefulness and acceptability. Additionally, written discharge instructions, which were part of the intervention materials, were distributed with QR-code and short URL link to surveys for patients to share their ED care experience. Patients were not prompted by any staff or research personnel to encourage use of the QR codes or the short URLs; however, a survey was conducted with ED waiting room patients in 3 urban EDs to ascertain whether they had downloaded a QR reader on their devices and the frequency of use of these applications. Results: Given the stepped-wedge nature of the study, these materials were available for a total of approximately 123 months (3 sites for 13 months, 4 sites for 10 months, 4 sites for 7 months, and 4 sites for 4 months). Over the study period, 15 patients accessed and completed the online survey linked to the QR code or the short URL placed on the posters. No patients completed the online surveys linked to the QR code or the short URL placed on the discharge instructions. The in-person survey conducted within the ED waiting room identified that 34% of respondents had a QR code reader downloaded on their phone (108/316). Of those with a QR reader, 33% reported using the reader at least once within the last 6 months. Conclusion: In this study, few patients downloaded QR readers on their electronic devices while in the ED waiting room. Without prompting, this appears to be an ineffective strategy for engaging patients in emergency medicine research. Other engagement strategies optimizing human resource investment are urgently needed to effectively conduct research in EDs.
P077: Piloting imaging-focused knowledge dissemination tools in Alberta emergency departments
Authors: Krebs L. , Hill N. , Villa-Roel C. , Couperthwaite S. , Ospina M. , Holroyd B. , Rowe B.
Published: May 2019

Introduction: Variation in image ordering exists across Alberta emergency departments (EDs). Evidence-based, pocket-sized knowledge dissemination tools were developed for two conditions (acute asthma [AA] and benign headache [BHA]) for which imaging (chest x-ray [CXR] and computed tomography [CT], respectively) has limited utility. This study explored tool acceptability among ED patients and emergency physicians (EPs). Methods: Tool feedback was provided by EPs, via online survey, and adult patients with AA and BHA via in-person survey. EPs qualitative interviews further explored communication tools. Preliminary descriptive analyses of survey responses and content analysis of interview data were conducted. Results: Overall, 55 EPs (55/192; 29%) and 38 consecutive patients participated in the AA study; 73 EPs (73/192; 38%) and 160 patients participated in the BHA study. In both studies, approximately 50% of EPs felt comfortable using the tool; however, they suggested including radiation risk details and imaging indications and removing references to imaging variation and health system cost. In the BHA study, EPs opposed the four Choosing Wisely® campaign questions fearing they would increase imaging expectations. In both conditions, most patients ( >90%) understood the content and 68% felt the information applied to them. Less than half (AA:45%; BHA: 38%) agreed that they now knew more about when a patient should have imaging workup done. Following tool review, 71% of AA and 50% of BHA patients stated they would discuss their imaging needs with their ED care provider today or during a future presentation. Both patient groups suggested including: additional imaging details (i.e., indications, risk, clinical utility), removing imaging overuse references, and including instructions that encourage patients to ask their EP questions. EP interviews (n = 12) identified preferences for personalized and interactive tools. Tensions were perceived around ED time pressure as well as remuneration schemes that fail to prioritize patient conversation. Tool centralization, easy access, and connection with outpatient support were also key themes. Conclusion: Both patients and EPs provided valuable information on how to improve ED knowledge dissemination tools, using two chronic conditions to demonstrate how these changes would improve tool utility. Implementing these recommendations, and considering preferences of EPs and patients, may improve future tool uptake and impact.
P085: What do community paramedics assess? An environmental scan and content analysis of patient assessment in community paramedicine
Authors: Leyenaar M. , McLeod B. , Penhearow S. , Strum R. , Brydges M. , Brousseau A. , Mercier E. , Besserer F. , Agarwal G. , Tavares W. , Costa A.
Published: May 2019

Introduction: Patient assessment is a fundamental feature of non-emergency community paramedicine (CP) home visit programs. In the absence of a recognized standard for CP assessment, current assessment practices in CP programs are unknown. Without knowing what community paramedics are assessing, it is difficult to ascertain what should be included in patient care plans, whether interventions are beneficial, or whether paramedics are meeting program objectives. Our objective was to summarize the content of assessment instruments used in CP programs in order to describe the state of current practice. Methods: We performed an environmental scan of all CP programs in Ontario, Canada, and employed content analysis to describe current assessment practices in CP home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. Findings were compared at the domain and sub-domain of the ICF. Results: Of 54 paramedic services in Ontario, 43 responded to our request for information. Of 24 services with CP home visit programs, 18 provided their intake assessment forms for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Overall, most assessments included some content from each of the domains outlined in the ICF, including: Impairments of Body Functions, Impairments of Body Structures, Activity Limitation and Participation, and Environmental Factors. At the sub-domain level, only assessment of Impairments of the Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems appeared in all assessments. Few CP home visit program assessments covered most ICF sub-domain categories and many items classified to specific categories were included in only a few assessments. Conclusion: CP home visit programs complete multi-domain assessments as part of patient intake. The content of CP assessments varied across Ontario, which suggests that care planning and resources may not be consistent. Current work on practice guidelines and paramedic training can build from descriptions of assessment practices to improve quality of care and patient safety. By identifying what community paramedics assess, evaluation of the quality of CP home visit programs and their ability to meet program objectives can be improved and benchmarks in patient care can be established.
P086: Awareness and barriers to access of a Ministry of Health mandated ‘Do Not Resuscitate’ confirmation form: An interim analysis
Authors: Lipkus M. , Manokara T. , Van Aarsen K. , Davis M.
Published: May 2019

Introduction: Elderly patients with comorbid illness have poor meaningful recovery after out of hospital cardiac arrest. Many elderly patients decide that if they have a cardiac arrest, they would want not want resuscitation. In Ontario, prehospital personnel must provide resuscitation to all patients regardless of previously stated wishes or legal documentation unless they are presented a Ministry of Health mandated ‘Do Not Resuscitate’ Confirmation Form (MOH-DNRCF). This study aimed to evaluate the awareness of this form as well as any barriers to its completion. Methods: Patients over 70 years of age presenting to the Emergency Department were approached to complete a short survey about their wishes regarding resuscitation, awareness of the MOH-DNRCF, as well as any barriers to completion. Standard demographic variables were also collected. Patients, with critical illness, with severe dementia, a language barrier or from a nursing home were excluded. The primary outcome was awareness of the MOH-DNRCF. Standard descriptive statistics were summarized using median [IQR] and simple proportions. Results: Preliminary data of 96 patients has been collected. The median [IQR] age of patients recruited was 81 [75-88] years and 54% were female. 49/96 (51%) have wishes to not be resuscitated in the event of cardiac arrest and of those 42 (86%) are not aware of the existence of the MOH-DNRCF. Of the 7 patients who were aware of the form only 1 had completed one. Barriers to completion included the patient being unsure where to access the form and difficulty in discussing the topic. Conclusion: The majority of patients with wishes to be DNR are unaware of the MOH-DNRCF. This has severe repercussions as, in the event of an out of hospital cardiac arrest, these patients would be resuscitated by prehospital care providers. Strategies to increase awareness of the form as well as strategies to increase ease of access should be considered to avoid resuscitation that is against patient wishes.
P087: Pilot project: Implementation of a peer support network for geographically distributed learners in the NOSM family medicine/emergency medicine residency program
Authors: Lyon T. , Ohle R.
Published: May 2019

Innovation Concept: Residents bear an enormous burden of responsibility for patient care which can lead to stress and mental exhaustion, especially in the face-paced and acute environment of emergency medicine (EM). In addition to numerous demands faced by EM residents, being a member of a geographically distributive residency program presents many unique challenges from a support and wellness perspective. To address these issues we sought to implement a video conferenced peer support network in hopes to foster wellness in the NOSM Family Medicine/EM program, where learners are commonly separated for training. Methods: Participants completed a pre-pilot questionnaire that strongly showed interest for this type of novel network. Furthermore residents conveyed that they are reluctant to access formal services and commonly rely on co-residents for support. This pilot program intends to decrease barriers that geography and stigma create that negatively hinder seeking support throughout medical training. Keeping the network small, consisting of only co-residents maintains a collegial and confidential environment that enables colleagues to provide relevant help to one another. Offering this outlet allows the opportunity to debrief and share unique experiences, which can lead to improved knowledge and wellbeing. Curriculum, Tool or Material: Informal, co-resident run and easy to access sessions are held twice monthly and average one hour in length. Discussion topics commonly include residency issues, difficult patient encounters and challenging situations. These sessions are conducted via video conferencing making them easily accessible from a distance and also from a comfortable and convenient environment of the participants choosing. Residents have commented that this is a helpful platform to discuss important issues while providing and safe and confidential resource to help cope with residency challenges. Conclusion: Further data analysis is underway as we are in the initial stages of implementing the program. In the final stages (April 2018) a pending post-pilot questionnaire will be interpreted to explore barriers, limitations and to determine the role of the network going forward. If found to be effective it is something that can be implemented and adapted for future residents. Other programs can use this feasible model to increase wellness and foster the same supportive environment among residents, especially those separated geographically from peers who may benefit most.
P092: Volunteer engagement in the emergency department: A scoping review
Authors: Glanz S. , Ellis B. , Nelson M. , Thompson C. , McLeod S. , Melady D.
Published: May 2019

Introduction: Little is known about the variety of roles volunteers play in the emergency department (ED), and the potential impact they have on patient experience. The objective of this scoping review was to identify published and unpublished reports that described volunteer programs in EDs, and determine how these programs impacted patient experiences or outcomes. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. A grey literature search was also conducted (Web of Science, ProQuest, Canadian Business and Current Affairs Database ProQuest Dissertations and Theses Global). Two reviewers independently screened titles and abstracts, reviewed full text articles, and extracted data. Results: The search strategy yielded 4,589 potentially relevant citations. After eliminating duplicate citations and articles that did not meet eligibility criteria, 87 reports were included in the review. Of the included reports, 18 were peer-reviewed articles, 6 were conference proceedings, 59 were magazine or newspaper articles, and 4 were graduate dissertations or theses. Volunteer activities were categorized as non-clinical tasks (e.g., provision of meals/snacks, comfort items and mobility assistance), navigation, emotional support/communication, and administrative duties. 52 (59.8%) programs had general volunteers in the ED and 35 (40.2%) had volunteers targeting a specific patient population, including pediatrics, geriatrics, patients with mental health and addiction issues and other vulnerable populations. 20 (23.0%) programs included an evaluative component describing how ED volunteers affected patient experiences and outcomes. Patient satisfaction, follow-up and referral rates, ED and hospital costs and length of stay, subsequent ED visits, medical complications, and malnutrition in the hospital were all reported to be positively affected by volunteers in the ED. Conclusion: This scoping review demonstrates the important role volunteers play in enhancing patient and caregiver experience in the ED. Future volunteer engagement programs implemented in the ED should be formally described and evaluated to share their success and experience with others interested in implementing similar programs in the ED.