bluuebunny/crossref_metadata_2025 huggingface dataset:
LO93: Prognostic value of S-100B protein for prediction of post-concussion symptoms following a mild traumatic brain injury: systematic review and meta-analysis
Authors: Mercier E. , Tardif P. , Cameron P. , Batomen Kuimi B. , Émond M. , Moore L. , Mitra B. , Frenette J. , De Guise É. , Ouellet M. , Bordeleau M. , Le Sage N.
Published: May 2017

Introduction: Mild traumatic brain injury (mTBI) is a major cause of morbidity but there are no validated tools to help clinicians predict post-concussion symptoms. This systematic review and meta-analysis aimed to determine the prognostic value of S-100B protein to predict post-concussion symptoms following a mTBI in adults. Methods: The protocol of this systematic review was registered with the PROSPERO database (CRD42016032578). A search strategy was performed on seven databases (CINAHL, Cochrane CENTRAL, EMBASE, MEDLINE, Web of Knowledge, PyscBITE, PsycINFO) from their inception to October 2016. Studies evaluating the association between S-100B protein level and post-concussion symptoms assessed at least seven days after the mTBI were eligible. Individual patient data were requested. Studies eligibility assessment, data extraction and risk of bias assessment were performed independently by two researchers. Analyses were done following the meta-analysis using individual participant data or summary aggregate data guidelines from the Cochrane Methodology Review Group. Results: Outcomes were dichotomised as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies presenting between seven and 223 patients (n=2505) were included. Post-concussion syndrome (PCS) (16 studies), neuropsychological symptoms (9 studies) and health-related quality of life (4 studies) were the most frequently presented outcomes. The S-100B protein serum level of patients with no PCS was similar to that of patients experiencing persistent PCS (mean difference 0.00 [-0.05, 0.04]) or early PCS (mean difference 0.03 [-0.02, 0.08]). The odds of having persistent PCS (OR 0.56 (95% CI: 0.29-1.10) or early PCS (OR 1.67 (95% CI: 0.98-2.85) in patients with an elevated S-100B protein serum level was not significantly different from that of patients with normal values. No meta-analysis was performed for other outcomes than PCS due to heterogeneity and small samples. Studies’ overall risk of bias was considered moderate. Conclusion: Results suggest that the prognostic value of S-100B protein serum level to predict persistent and early post-concussion symptoms is limited. Variability in injury to S-100B protein sample time and outcomes assessed could potentially explain the lack of association and needs further evaluation.
LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay
Authors: Andruchow J. , McRae A. , Abedin T. , Wang D. , Innes G. , Lang E.
Published: May 2017

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.
MP06: Use of ultrasound and x-ray to predict improvement in hip osteoarthritis symptoms following intra-articular steroid injection
Authors: Steer K. , Nguyen T. , Woodhouse L. , Bostick G. , Smith B. , McGoey J. , Lambert R.G. , Jaremko J.
Published: May 2017

Introduction: Intra-articular steroid injection (IASI) is commonly used in the emergency department for management of osteoarthritis (OA) symptoms. Hip IASI carries risks, such as avascular necrosis, and there is currently no reliable way to predict long-term response of a patient’s OA to IASI. Ultrasound (US) conveniently assesses for active arthropathy by detecting effusion-synovitis, and x-ray (XR) is useful for visualizing bone-related changes. We investigated the extent that a response to hip IASI could be predicted from baseline OA patient clinical and physical features alongside US and XR imaging features. Methods: 97 consenting patients with symptomatic hip OA presenting for hip IASI were evaluated at baseline (XR and US) and again 8-weeks after IASI (US only). Self-reported pain (WOMAC), hip range of motion (ROM) were measured at baseline and follow up. On US images we quantified joint effusion and synovial thickening, i.e., “effusion-synovitis”, by the bone-capsule distance (BCD) at the apex of the femoral head from outer femoral cortex to outer synovium. On XR, we measured minimum joint space width (cm) and Kellgren-Lawrence (K-L) Grade for osteophytes and sclerotic changes. Results: In our 97 patients (43 female) aged 28-87 years (mean 59+/-13 years, K-L grades averaged 2.5+/-1.5, and US BCD averaged 5.9+/-2.0 mm. We performed multiple linear regression using age, sex, BMI, ROM of hip flexion, US BCD, radiographic joint space width and K-L grade against the dependent variable, change in WOMAC pain subscore (R=0.587, P=0.002). We compared the response predicted by this model to the actual change in WOMAC pain. At a threshold value of -20% for minimal clinically important difference, 35/97 patients were responders, and a 2x2 table gave 67% overall model predictive accuracy, 61% sensitivity, and 71% specificity. Likelihood ratio for a positive response (LR+) was 2.13. Conclusion: Combining radiographic information on structural damage, US information on active arthropathy, and demographics correctly predicted about two-thirds of the patients that would benefit from IASI after 8 weeks. A patient with hip OA that met our model criteria was more than twice as likely to respond to IASI. With further model refinement, effective, personalized evidence-based management of symptomatic hip OA is possible using XR and hip US, which could both be performed during an ER visit.
MP13: Characteristics and outcomes of older emergency department patients assigned a low acuity triage score
Authors: Hendin A. , Eagles D. , Myers V.R. , Stiell I.G.
Published: May 2017

Introduction: Older patients are a high-risk population in the Emergency Department (ED) for poor outcomes after ED visit, including return presentation and hospital admission. Little is known however about outcomes in older patients identified as “low acuity” by triage. We aim to describe the characteristics, ED workup, disposition, and 14-day outcomes of ED patients 65 years and up who are triaged as low acuity and compare them to a younger cohort. Methods: This health records review was done in a Canadian tertiary care ED. Included patients received a Canadian Triage Acuity score (CTAS) of 4 or 5 and were either 65 years and up (“older” group), or 40-55 years (controls). Data collected included patient demographics, tests and services involved in ED, and disposition. Return ED visit and hospital admission rates at 14 days were tracked. Data were analyzed descriptively and chi-square testing conducted to assess for differences (p < 0.05) between groups. A pre-planned stratified analysis of patients 65-74 years, 75-84, and 85 and older was conducted. Results: 350 patients (mean age 76.5, 56.6% female) were included in the older group and 150 in the control group (mean age 47.3, 55.3% female). Most patients presented with musculoskeletal or skin complaints (older cohort: 28.6% extremity pain/injury, 10% rash, 8.9% laceration, versus control 30% extremity pain/injury, 14.7% rash, 14.0% laceration) and were triaged to the ambulatory care area (88.6% elderly, 99.3% control). Older patients were significantly more likely than younger controls to be admitted on index visit (5.0% vs 0.3% admit rate, p=0.016). They had a trend towards increased re-presentation rates within 14 days (13.7% vs 8.7% control, p=0.11) and were more likely to be admitted on re-presentation (4.0% vs 0.7%, p=0.045). In sub-group analysis, very elderly patients (85 years and up, n=79) were more likely to be admitted (8.9%, p=0.003). Conclusion: Patients 65 years of age and older who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients 85 years and up are the primary drivers of this higher admit rate. This study characterizes “low acuity” elders presenting to ED and indicates these patients are high risk for re-presentation and admission within 14 days.
MP18: A patient focused information design intervention to support the mTBI Choosing Wisely recommendation
Authors: Hair H. , Boudreau D. , Rice C. , Grigat D. , VandenBerg S.D. , Ruhl G. , Dowling S.
Published: May 2017

Introduction: Within Alberta, 30% of patients presenting to emergency with minor traumatic brain injury (mTBI) will receive a CT scan before being sent home, regardless of whether it was clinically indicated. Choosing Wisely (CW) Canada recommends using validated clinical decision support to determine whether a CT scan is necessary for patients presenting with a mTBI. In order to provide patients with information on the risks and benefits of CT scans in mTBI and to encourage discussions between patients and their doctor, the Emergency StrategicClinical Network (ESCN) designed a patient focused information visualization on CT scans for head injuries. Methods: The ESCN, Physician Learning Program and CW Alberta partnered with the Mount Royal University Department of Information Design to develop a patient information visualization (infographic) intervention. Students spent a semester developing these infographics on Choosing Wisely recommendations, which were then presented to stakeholders. A student was then selected to develop a final design. Refinement of the design took place in consultation with clinical experts and tested in two patient focus groups. The final design was evaluated against the International Patient Decision Aid Standards checklist. The infographic was posted in 2 local emergency department waiting rooms. A survey was administered to any patients in the waiting room when volunteers were available. The survey was designed to evaluate whether the tool influenced patient beliefs about the risks and benefits of CT scans, and their willingness to engage in a discussion with their doctor. Results: In a 26 day period, 90 patients consented and completed the survey. Before reading the infographic, 33% of patients thought that after a head injury a CT was always a good idea and 63% thought it was sometimes a good idea. 82% and 91% of patients stated the poster helped them understand the indications and risks of CT imaging for mTBI. After viewing the poster, only 15% of patients felt that a CT was always a good idea after a mTBI. Conclusion: The mTBI patient infographic significantly changed patient perceptions regarding the need for CT scans in the setting of mTBI. This study demonstrates that targeted patient education materials can help support CW recommendations.
MP21: An interprofessional delirium assessment tool for healthcare professionals and trainees working in the emergency department
Authors: Balasubramanaiam B. , Chenkin J. , Snider T.G. , Melady D. , Lee J.S.
Published: May 2017

Introduction: Multiple studies since the ‘90’s demonstrate that ED staff fail to identify delirium in up to 75% of older patients. Those patients who are discharged have a 3-fold increased mortality. Methods: We iteratively developed a 14-item interprofessional tool with 4 clinical vignettes to assess comfort, knowledge and ability to identify delirium among medical students, EM residents, staff MDs and RNs. We conducted a prospective observational study using modified Dillman survey methodology. Surveys were sent on paper to residents and nurses and online to medical students and staff MDs. Results: Our response rate was 68% (38/56) for residents, 80%(16/20) for RNs; but only 37%(13/35) for staff MDs and 13%(139/1036) for medical students. Comfort with identifying delirium increased with level of medical training; 38/139(27%) 1st-4th year medical students (MS1-MS4); 25/38(66%) 1st-5th year residents (R1-R5); and 12/13(92%) staff physicians reported being comfortable (χ2=34.7, df=2, p<0.001). MS1-MS2 were the least comfortable, with only 5/82(6%) reporting comfort, increasing to 33/57(58%) among MS3-MS4 (χ2=44.9, df=1, p<0.001). A greater proportion of R4-R5 who completed a geriatric emergency medicine (Geri-EM) curriculum reported comfort, 11/12(92%) compared to 14/26(54%) of R1-R3 (χ2=19.2, df=1, p<0.05). Only 5/16(31%) nurses reported being comfortable with identifying delirium. Ability to identify all 4 clinical vignettes correctly was higher among MS3-MS4 than MS1-MS2 (32/57(56%) vs. 30/82(37%), χ2=5.2, df=1, p<0.05). There was no difference between respondents from different levels of medical training (62/139(45%) MS1-MS4, 21/38(55%) R1-R5 and 6/13(46%) staff MDs, χ2=1.4, df=2 p=0.52). There was no effect of Geri-EM completion on perfect vignette scores (6/12(50%) R4-R5 vs. 15/26(58%) R1-R3, χ2=0.20, df=1, p=0.66). There was a trend towards a lower proportion of nurses who identified all 4 clinical vignettes correctly compared to physicians (4/16(25%) vs. 27/51(53%), χ2=3.82, df=1, p=0.051). Conclusion: Our tool may be useful for assessing comfort and knowledge of delirium among ED physicians and nurses. Completion of the Geri-EM curriculum was associated with increased comfort with detecting delirium but not knowledge. Future studies should assess current ED delirium comfort and knowledge at different levels of training; between professions and examine differences nationwide.
MP25: The role of advanced imaging in the management of benign headaches in the emergency department: a systematic review
Authors: Lepage R. , Krebs L. , Kirkland S.W. , Alexiu C. , Campbell S. , Rowe B.H.
Published: May 2017

Introduction: Headache is a common emergency department (ED) presentation. Benign (i.e., non-pathological) headaches are particularly common, including exacerbations of chronic migraine, tension, and cluster headache. Several studies have reported concerns over the frequent use of advanced imaging, specifically computed tomography (CT), in the ED management of benign or primary headache presentations. This systematic review examined the proportion of adult ED benign headache presentations who receive a CT(head). Methods: Eight bibliographic databases and the grey literature were searched. All studies reporting the proportion of benign headache patients receiving a CT(head) in the ED were eligible for inclusion. Studies which included a secondary headache population of 15% of their total study population or less where eligible for inclusion. Two reviewers independently assessed study inclusion and completed quality assessment and data extraction. Weighted medians were calculated for the primary and secondary outcomes, as appropriate. Results: The search returned 2,444 unique citations, of which 20 met the inclusion criteria (21 patient groups were analyzed). The majority of the studies were descriptive in nature and conducted in North America. The reported proportion of benign headache patients receiving a CT(head) varied considerably (range: 2.06-67.21%); with a weighted median of 30.0% (interquartile range: 30.0, 30.0). Studies published in 2000 or later (18/21 groups) were found to have a higher weighted median percentage compared to those published pre-2000 (p=0.016). Neither the country of origin nor the proportion of patients with secondary headache included within the study population had a significant effect on CT utilization. Of the three studies which reported the discharge diagnosis of all patients, sub-arachnoid hemorrhage was discovered in 2/241 (0.83%) of CT scans. Conclusion: Considerable variation in CT utilization for benign headache ED presentations exists and estimates indicate that more than a quarter of patients receive a CT(head). Overall, these CT scans rarely identify significant pathology, suggesting imaging may be safely reduced. Further research is required to identify interventions which can safely and effectively reduce unnecessary imaging among headache presentations.
MP28: A randomized comparative trial of the usage, knowledge retention and media preferences in undergraduate medical students using podcasts and blog posts
Authors: Lien K. , Chin A. , Helman A. , Chan T.M.
Published: May 2017

Introduction: Podcasts and blog posts are gaining popularity in Free Open Access Medical education (FOAMed). However, there remains a paucity of research comparing the two media for undergraduate medical education. This study aims to investigate if there are differences in medical students’ usage conditions, knowledge retention and preferences in the two types of media (podcasts, blog posts). Methods: Medical students were block-randomized to either the podcast or blog post group according to their year of schooling. They completed an online assessment of their baseline knowledge on the subject matter and preferences within the various types of media. Participants then received access to learning materials and were given four weeks to complete the follow-up assessment. Simple descriptive statistical data were used to detail student preferences. Paired samples t-tests and a Repeated Measures Analysis of Variance (RM-ANOVA) were conducted to assess knowledge acquisition. A carry forward analysis was used to impute missing data from students lost to follow-up. Results: A total of 65 medical students participated in our study (podcasts n=33, blog posts n=32). The initial survey suggests that students prefer general topic discussion and “approach-to” themes (68% and 84%, respectively). 55% of students in the podcast group preferred podcasts that were less than 30 minutes. None of the blog post group preferred a shorter text, and each blog post required a mean of 25 minutes to read. Completion of at least one follow-up assessment was comparable (68% podcasts, 70% blog posts). The podcast listeners tended to engage in multiple activities while using the learning material (e.g. at least 2-3 of the following: driving, eating, chores, taking notes, exercising), while the blog readers tended to do fewer activities (e.g. only 1 of the following: taking notes, eating, only reading). Both groups showed significant improvements in their test scores (Asthma: 22% improvement, Toxicology: 29%; p<0.01 for both), with blog posts demonstrating a larger but non-significant difference (RM-ANOVA, Topic*Modality F(1,59)=0.001, p=0.973). Conclusion: This study suggests that podcasts and blog posts significantly improve medical student knowledge retention to a similar degree, but differ in usage conditions.
P002: Do 5th metatarsal fractures need to be managed by orthopaedic surgeons?
Authors: Meschino D. , Adamich J.S. , Camp M.
Published: May 2017

Introduction: There is increasing evidence that emergency room physicians or primary care physicians can definitively manage many uncomplicated paediatric fractures without orthopaedic follow-up. This strategy leads to a reduction in radiation exposure and decreased costs to patient families and the healthcare system without impacting patient outcomes. The aim of this study was to determine whether patients who sustained an isolated 5th metatarsal fractures require orthopaedic surgeon follow-up. Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of metatarsal fractures from 2009-2014 was performed. Results: 124 patients (66 males, 58 females) with mean age of 11.3 (SD=2.9) years old were included in the study. Complications were minimal with no patients requiring operative management. There were zero non-unions and 3 delayed unions. Despite zero instances of surgical correction and a low complication rate, fracture clinic resource utilization was substantial. Fractures were managed with a mean number of 3.1 (SD=0.98) clinic visits, including initial evaluation in the emergency department. A mean number of 2.8 (SD=1.1) radiology department visits were conducted, with a mean of 8.1 (SD=3.8) x-rays total per patient. Conclusion: Our series supports reduced clinical follow-up of patients with isolated 5th metatarsal fractures. If the diagnosis can be made on the initial radiographs, ER physicians or primary care providers can definitively manage these patients with appropriate immobilization. A fracture clinic follow-up is only necessary if the diagnosis cannot be made on the initial radiographs. Our clinical care pathway will reduce radiation exposure and reduce costs incurred by the healthcare system and patients’ families without jeopardizing patient outcomes.
P006: Characterizing patients with newly-diagnosed diabetes mellitus in the emergency department: A one-year health records review
Authors: Ali Khan H. , Gushulak K. , Columbus M. , Stiell I.G. , Yan J.W.
Published: May 2017

Introduction: Diabetes mellitus is an increasingly prevalent chronic condition that is usually managed in an outpatient setting. However, the emergency department (ED) plays a crucial role in the management of diabetic patients, particularly for those who are presenting with newly diagnosed diabetes. Little research has been done to characterize the population of patients presenting to the ED with hyperglycemia with no previous diagnosis of diabetes. The objective of this study was to describe the epidemiology, treatment, and outcomes of patients who were newly diagnosed with diabetes in the ED and to compare those with newly diagnosed type I versus type II diabetes. Methods: A one-year health records review of newly diagnosed diabetes patients ≥18 years presenting to one of four tertiary care EDs was conducted. All patients with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome were screened, but only those who did not have a previous history of diabetes were included. Trained research personnel collected data on patient characteristics, management, disposition, and outcome. Descriptive statistics were used to summarize the data where appropriate. Results: Of 645 patients presenting with hyperglycemia in the study period, 112 (17.4%) were newly diagnosed diabetes patients. Of these patients, 30 (26.8%) were later diagnosed with type I diabetes and 82 (73.2%) were diagnosed with type II diabetes. For the newly diagnosed type I patients the mean (SD) age was 27.6 (9.9) and the mean (SD) age for type II patients was 52.4 (14.1). Of all the new onset patients, 26.8% were diagnosed with diabetic ketoacidosis. The percentage of patients diagnosed with diabetic ketoacidosis was higher in type I than type II (63.3% vs 13.4%; P<0.01). A total of 49 (43.8%) patients were admitted to the hospital, and more patients with type I were admitted compared to those with type II (66.7% vs 35.4 %; P<0.01). Conclusion: Limited research has been done to describe patients newly diagnosed with diabetes in the ED. Patients with type I were found to be more likely to present to the ED with serious symptoms requiring admission to hospital. Our findings demonstrate that the ED may have a strong potential role for improving diabetic care, by providing future opportunities for education and follow-up in the ED to reduce complications, particularly in type I.
P008: Implementation of a voluntary provincial knowledge translation intervention project to improve the appropriateness of CT imaging for patients with mild traumatic brain injury and suspected pulmonary embolism
Authors: Andruchow J. , Grigat D. , McRae A. , Innes G. , Lang E.
Published: May 2017

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes. Previous attempts to improve imaging appropriateness via guideline implementation have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this project is to improve CT utilization and appropriateness by addressing common barriers through clinical decision support (CDS) embedded in clinical practice. Methods: This matched-pair cluster-randomized trial saw 12 Alberta EDs with CT scanners randomized to receive CDS for diagnostic imaging. After extensive site engagement to recruit emergency medicine and diagnostic imaging leadership and stakeholders and understand local contexts, half of the sites received CDS for mild traumatic brain injury (MTBI) based on the Canadian CT Head Rule, while the remainder received CDS for suspected pulmonary embolism (PE), including the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT pulmonary angiography (CTPA) use. Hardcopy CT order forms including quantitative decision support, source literature and patient handouts were developed and adapted and integrated into workflow as per local site preference. Regular physician and site report cards on CT utilization and CDS use were also provided. The primary outcome was diagnostic imaging utilization for patients with MTBI and suspected PE. Results: During the study period, 144 emergency physicians at 6 EDs saw 3,278 patients with MTBI and 146 emergency physicians at six matched comparison EDs saw 18,606 patients with suspected PE. Use of CDS was highly variable by site, ranging from 0% to 29% of CT orders for MTBI and from 13% to 75% of CTPA orders for suspected PE. Impact on CT utilization, appropriateness, diagnostic yield is currently under investigation, but is expected to be limited at many sites given the variable adoption of decision support. Conclusion: A comprehensive CDS intervention to improve evidence-based imaging has met with variable uptake. Meaningful and widespread sustained improvements in practice will likely require incentives, accountability measures and leadership authority to enforce change.
P014: Palliative and end of life care education in Canadian emergency medicine residency programs: a national cross-sectional survey
Authors: Baylis J. , Harris D.R. , Chen C. , Ting D.K. , Kwan A. , Clark K. , Williscroft D.
Published: May 2017

Introduction: Palliative care is a broad approach to care for patients with serious or life-threatening illnesses. This includes relief of symptoms, such as pain, that interfere with a patient’s quality of life. It therefore falls firmly within the realm of emergency medicine (EM). 94% of emergency physicians report a need for education in dealing with death and dying. Nevertheless, there are no generally agreed upon competencies for Canadian EM residents with regard to palliative care and end of life care in the emergency department (ED). We performed a cross-sectional study of Canadian EM residency programs to measure the existing curricula in palliative and end of life care. Our primary outcome was the prevalence of structured educational programs for palliative and end of life care. Methods: An e-survey was e-mailed to all program directors of both CCFP(EM) and EM post-graduate training programs countrywide, using FluidSurveysTM. It included questions regarding current palliative and end of life care curricula from formal rotations to seminars and online modules. The survey was developed in consultation with the author group including specialists in education, palliative care medicine, emergency medicine, and medical education. Hired translators were employed to include French speaking programs in Canada. This study had ethical approval: Interior Health REB and UBC CREB certificate 2016-17-026-H. Results: The survey was open from October 12th to December 19th, 2016. During that time, we received 26 responses including 5 French speaking programs, for a response rate of 72.2%. The primary outcome was present in 38.5% of programs. There was no difference between FRCP and CCFP(EM) programs in the occurrence of the primary outcome (p=1; Fisher’s Exact Text). However, CCFP(EM) program directors commented that many of their residents had completed palliative care rotations in their family medicine training. The largest barriers to education included time (84.6%), curriculum development (80.8%), and availability of instructors (50.0%). Conclusion: Our preliminary analysis shows that few Canadian post-graduate EM programs have a structured educational program pertaining to palliative and end of life care. Current barriers to education that can be addressed in future curricular initiatives include lack of time, curriculum development, and instructor availability.
P015: Leadership and administration: a novel elective rotation for emergency medicine residency training
Authors: Baylis J. , Harris D.R. , Ertel M. , Clark K.
Published: May 2017

Introduction/Innovation Concept: In 2015, the Royal College of Physicians and Surgeons of Canada set out to redefine the CanMEDS roles including replacement of the “manager” role to that of the “leader”. This was to highlight the fact that skills in leadership are crucially important as ongoing health care improvement occurs. This educational innovation was born out of a need for formal education in leadership and administration in post graduate emergency medicine training. Methods: Few post graduate emergency medicine training programs in Canada have leadership and administrative curricula involving either longitudinal or discrete 4 week rotations. We sought to create an evidence based leadership and administrative experience based on the CanMEDS roles. We adapted components of pre-existing rotations from other universities and selected competencies from Thoma et al in order to compile a list of objectives. This was coupled with a reading list, various departmental, hospital, and regional meetings, a physician leadership training seminar, a departmental presentation, and a leadership project. Curriculum, Tool, or Material: The curriculum involved 4 weeks combining 8 emergency department (ED) clinical shifts with a leadership and administration component. The latter involved clinical interdepartmental meetings, a hospital medical advisory council (MAC) meeting, a provincial medical directors meeting, a health authority MAC meeting, and taking part in planning for an ED quality improvement initiative focused on triage. Attendance at a 2-day physician administrator leadership training seminar was also included. The reading list included books on leadership and references to ED quality improvement. In addition, exposure to a B.C. Ministry of Health document entitled, “Setting Priorities for the Health Care System,” the KGH Medical Staff Rules, and the B.C. Health Quality Matrix occurred. A summary presentation to the full ED on change management and leadership in residency occurred at completion. Conclusion: This innovative leadership and administration elective was the culmination of a need to see more formal post graduate leadership training in residency. The rotation was based on the CanMEDS framework, particularly the “leader” competency, and was based on recent evidence regarding leadership and administration competencies in emergency medicine. We hope this serves as a potential model for other rotation based electives or core rotations that desire to blend leadership competencies with clinical emergency medicine.
P016: Low risk ankle rule, high reward-a quality improvement initiative to reduce ankle x-rays in the pediatric emergency department
Authors: Al-Sani F. , Ben-Yakov M. , Harvey G. , Gantz J. , Jacobson D. , Boutis K. , Ostrow O. , Principi T.
Published: May 2017

Introduction: Our tertiary care institution embarked on the Choosing Wisely campaign to reduce unnecessary testing, and selected the reduction of ankle x-rays as part of its top five priority initiatives. The Low Risk Ankle Rule (LRAR), an evidence-based decision rule, has been derived and validated to clinically evaluate ankle injuries which do not require radiography. The LRAR, is cost-effective, has 100% sensitivity for clinically important ankle injuries and reduces ankle imaging rates by 30-60% in both academic and community setting. Our objective was to significantly reduce the proportion of ankle x-rays ordered for acute ankle injuries presenting to our pediatric Emergency Department (ED). Methods: Medical records were reviewed for all patients presenting to our tertiary care pediatric ED (ages 3- 18 years) with an isolated acute ankle injury from Jan 1, 2016-Sept 30, 2016. Children with outside imaging, an injury that occurred >72 hours prior, or those who had a repeat ED visit for same injury were excluded. Quality improvement (QI) initiatives included multidisciplinary staff education about the LRAR, posters placed within the ED highlighting the LRAR, development of a new diagnostic imaging requisition for ankle x-rays requiring use of the LRAR and collaboration with the Division of Radiology to ensure compliance with new requisition. The proportion of patients presenting to the ED with acute ankle injuries who received x-rays was measured. ED length of stay (LOS), return visits to the ED and orthopedic referrals were collected as balancing measures. Results: At baseline 88% of patients with acute ankle injuries received x-rays. Following our multiple interventions, the proportion of x-rays decreased significantly to 54%, (p<0.001). This decrease in x-ray rate was not associated with an increase in ED LOS, ED return visits or orthopedic referrals. There was an increase uptake of the dedicated x-ray requisition over time to 71%. Conclusion: This QI initiative to increase uptake of the LRAR, resulted in a significant reduction of ankle x-rays rates for children presenting with acute ankle injuries in our pediatric ED without increasing LOS, return visits or need for orthopedic referrals for missed injuries. Just as in the derivation and validation studies, the reductions have been sustained and reduced unnecessary testing and ionizing radiation.
P020: Ultrasound-guided peripheral intravenous access in the emergency department: A randomized controlled trial comparing single and dual-operator technique
Authors: Brick C. , Chenkin J. , Chang Y.R. , Kapur P.
Published: May 2017

Introduction: Intravenous (IV) cannulation is a common and important procedure in the emergency department (ED). Ultrasound-guided IV (UGIV) insertion has been shown to be more effective than the blind approach for patients with difficult IV access. The optimal technique for UGIV insertion has not been determined. The objective of this study is to compare the first-attempt canulation success rate between a single-operator technique (provider holds the ultrasound probe while simultaneously placing the IV), with dual-operator technique (whereby a second provider holds the probe) in ED patients with predicted difficult access. Methods: We conducted a randomized controlled trial using a convenience sample of adult ED patients. Participating ED nurses received a one-hour UGIV training session on including didactic and practical training on simulated arms. Patients were enrolled if they met any of three criteria for difficult access: (1) history of difficult access, (2) no visible or palpable veins, or (3) two failed blind attempts. High-acuity patients or those unable to consent or comply with the procedure were excluded. Eligible patients were randomized to single or dual-operator technique and a maximum of two UGIV attempts were allowed. The primary outcome was first-attempt success rate. Additional outcomes included overall success rate, number of attempts, time to successful cannulation (needle insertion to flashback), patient pain scores, operator ‘ease of use’ scores, and complications 30 minutes after insertion including IV failure. Other variables collected included patient demographics, presenting complaint, indication for ultrasound use, relevant medical history, and location/depth of the target vessel. Fisher’s exact test was used to compare success rates between groups. Results: Data collection was ongoing at the time of submission, but is expected to be completed by May 01, 2017. Conclusion: This is the first randomized-controlled trial comparing single and dual-operator ultrasound technique for difficult IV insertion in ED patients. The results from this study will provide evidence to guide education, and ensure best practice of UGIV insertion in the ED.
P028: The prevalence of pathological findings identified by next day abdominal ultrasound in patients discharged from the ED
Authors: Cargnelli S. , Thompson C. , Dear T.E. , Sandre A. , Borgundvaag B. , McLeod S.L.
Published: May 2017

Introduction: Abdominal pain is the most common complaint in the emergency department (ED), accounting for approximately 7% of all visits. Of the patients discharged from the ED with this complaint, 25% will carry a diagnosis of undifferentiated abdominal pain and many will subsequently have an outpatient ultrasound for further assessment. The objective of this study was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days. Methods: This was a retrospective chart review of non-pregnant patients aged 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound from November 2014 to November 2015. Data was abstracted by trained research personnel independently and in duplicate and inter-rater agreement was calculated for 25% of charts. Results: Of the 315 included patients, 261 (82.9%) were female and mean (SD) age was 28.5 (5.9) years. 28 (8.9%) patients had ultrasounds requiring intervention within 14 days. Of these, 8 (28.6%) had appendicitis, 6 (21.4%) had cholecystitis, 5 (17.9%) had gynecological, 5 (17.9%) had urological and 4 (14.3%) had gastrointestinal diagnoses. However, 15 (53.6%) patients requiring intervention within 14 days had symptoms which had improved or resolved at the time of the US. Of the 287 (91.1%) patients not requiring intervention, 92 (32.1%) had unchanged, 120 (41.8%) had improved, 52 (18.1%) had resolved and 5 (1.7%) had worsened symptoms at the time of follow-up. Of the non-intervention patients, 13 (4.5%) required alternative imaging (CT scan). Conclusion: The large majority of patients with abdominal pain discharged from the ED with planned next day US were found to have either no pathology or pathology that did not require further ED management. However, 8.9% of patients had pathological findings requiring intervention within 14 days and half of these had symptoms that had resolved or improved at the time of the US. Next day US imaging remains a viable option for identifying patients with serious pathology not appreciated at the time of their ED visit.
P029: Paramedic and nurse-staffed rural collaborative emergency centres: the rate of relapse for discharged patients
Authors: Carter A. , Cook J. , Beals M. , Goldstein J. , Travers A. , Jensen J. , Dobson T. , Carrigan S.A. , Vanberkel P.
Published: May 2017

Introduction: Collaborative Emergency Centres (CECs) provide access to care in rural communities. After hours, registered nurses (RNs) and paramedics work together in the ED with telephone support by an emergency medical services (EMS) physician. The safety of such a model is unknown. Relapse visits are often used as a proxy measure for safety in emergency medicine. The primary outcome of this study is to measure unscheduled relapses to emergency care. Methods: The electronic patient care record (ePCR) database was queried for all patients who visited two CECs from April 1, 2012 to April 1, 2013. Abstracted data included demographics, time, acuity score, clinical impression, chief complaint, and disposition. Records were searched for each discharged CEC patient to identify unscheduled relapses to emergency care, defined as presenting back to EMS, CEC, or any other ED within the Health Authority within 48 hours of CEC discharge. Results: There were 894 CEC visits, of which 66 were excluded due to missing data. The dispositions from CEC were: 131/828 (15.8%) transferred to regional ED; 264/828 (31.9%) discharged home; 488/828 (58.9%) discharged with follow up visit booked; and 11/82 (1.2%) left the CEC without being seen. There was 37/828 (4.5%) visits which relapsed back to emergency care, all of whom were discharged from CEC or left without being seen: 3/828 (0.4%) relapsed back to EMS (two taken to regional ED and one to CEC); 16/828 (1.9%) relapsed to regional ED (by walking-in); and 18/828 (2.2%) had a relapse to the CEC (walk-in). 516/828 (62.3%) CEC visits were resolved in a single visit. Conclusion: This study was based on only two of the 7 operating CECs due to accessing paper-based charts for multiple health regions. We also acknowledge the limitations of using relapse as a proxy for safety, and that low volumes and acuity will make detection of adverse events challenging. Albeit a proxy measure, the rate of patients who relapse to emergency care was under 5% in this case series of two CECs. Most patients had their concern resolved in a single visit to a CEC. Further research is underway to determine the effectiveness, optimal utilization and safety of this collaborative model of rural emergency care.
P030: Multisource feedback for emergency medicine residents: different, relevant and useful information
Authors: Castonguay V. , Lavoie P. , Karazivan P. , Morris J. , Gagnon R.
Published: May 2017

Introduction/Innovation Concept: Feedback provided to residents by physicians emphasize the medical expertise competency and may limit the attention paid to other CanMEDS competencies. Recent years have seen the emergence of the concept of multisource feedback, a process through which different members of the care team assess and provide feedback to residents. This approach is considered one of the best for providing relevant feedback on competencies that are less often addressed by physicians. To date, very few studies have explored emergency residents’ perceptions following feedback from their physicians, nurses with whom they have worked, and patients they have treated. Methods: In the emergency department of a tertiary-care university hospital, 10 emergency medicine residents participated, on a voluntary basis, in individual and semi-structured group interviews, three months after having received multisource feedback. Two researchers then qualitatively analyzed the data collected in those interviews. Thematic content analysis using QDA Miner identified dominant themes in the residents’ perceptions. Curriculum, Tool, or Material: Multisource feedback tool: Three questionnaires were designed to gather assessment from different sources: physicians, nurses, and patients. The questionnaires were adapted from those created by Joshi and colleagues for use in a study of residents’ competency in interpersonal and communication skills. During a nine months period, the residents distributed questionnaires to physicians, nurses, and patients with whom they felt they had enough interactions during their clinical shifts. Data from the questionnaires were compiled by two educators that prepared individual feedback reports for each resident. An educator was asked to conduct individual meetings with each resident to present the feedback report and discuss its content. Conclusion: Each source provided relevant comments that differed significantly in their content. Physicians focused primarily on medical expertise, whereas nurses addressed competencies related to management, collaboration, and communication, and patients commented on the competencies of professionalism and communication. Residents concluded that obtaining feedback from nurses and patients was not only acceptable but useful in their training. Several reported modifying certain behaviours after receiving the multisource feedback. Multisource feedback appears to have obvious teaching potential to provide feedback on competencies other than medical expertise in emergency residents.
P036: A comprehensive quality improvement initiative to prevent falls in the emergency department
Authors: Samuel P. , Park J. , Muckle F. , Lexchin J. , Mehta S. , Mcgovern B. , Chartier L.B.
Published: May 2017

Introduction: Patients from all population groups visit the emergency department (ED), with increasing visits by elderly patients. Patient falls in the ED are a significant safety concern, and they can lead to serious injuries and worse outcomes. Toronto Western Hospital’s ED Quality Improvement (QI) team identified as a problem our assessment and management of patients at risk for falls. The aim of this project was to develop a comprehensive and standardized approach to patients at risk of falls in the ED, including implementing timely interventions for fall prevention. Methods: A literature review of existing tools was completed to develop our own reliable and valid fall risk screening tool for ED patients. QI methods were used to devise a comprehensive strategy starting with detection at triage and implementation of action-driven steps at the bedside, through multiple PDSA cycles, randomized audits, surveys, and education. Repeated measurements were undergone throughout the project, as were staff satisfaction surveys. Results: The chart audits showed a five-fold increase in the completion rate of the fall risk screening tool in the ED by the end of the QI initiative (from 10% to 50%). Constructive feedback by an engaged team of nurses was used to iteratively improve the tool, and there was mostly positive feedback on it after various PDSA cycles were completed. The various component of this novel and useful ED-based falls screening tool and bundle will be presented in tables and figures for other leaders to replicate in their EDs. Conclusion: We developed a completely new ED-specific fall risk screening tool through literature review, front-line provider feedback, and iterative PDSA cycles. It was used for the identification, prevention, and management of ED patients with fall risk. We also contributed to a positive change in the culture of a busy ED environment towards the promotion of patient safety. Education and feedback continue to be provided to the ED nurses for reflective practice, and we hope to continue to improve our tool and to share it with other EDs.