bluuebunny/crossref_metadata_2025 huggingface dataset:
MP028: Dynamic changes of prehospital serial 12-lead electrocardiogram for remote diagnosis of suspected ST-segment elevation myocardial infarction
Authors: Lau L. , Lebon J. , Begin F. , Tanguay A.B.
Published: June 2016

Introduction: Accurate and efficient interpretation of prehospital 12-lead electrocardiogram (ECG) in patients with suspected ST-segment elevation myocardial infarction (STEMI) can improve outcomes, especially in rural regions. In the Chaudière-Appalaches region, Quebec, a prehospital serial 12-lead ECG monitoring system is used for remote interpretation of ECG abnormalities by emergency physicians via a telemedicine platform, the Unité de Coordination Clinique des Soins Préhospitaliers d'Urgence (UCCSPU). The objective of the study was to evaluate the use of serial monitoring of dynamic ECG changes in patients with suspected STEMI during emergency medical services (EMS) transport. Methods: A retrospective cohort study with suspected STEMI patients monitored with prehospital serial ECGs was performed from August 2006 to December 2013. The data was extracted from UCCSPU clinical databases and verified by an emergency physician supervisor. During EMS transport, the serial ECG monitoring system automatically produced and transmitted every 2 minutes a 12-lead ECG without artefacts. STEMI criteria were based on the Third Universal Definition of Myocardial Infarction. Dynamic ECG change was defined as an ST-segment elevation or depression that meets diagnostic criteria (eg. initial non STEMI (NSTEMI) changing to STEMI and vice versa). Results: Among the 752 patients identified with suspected STEMI, 728 (96.8%) were included in the study due to missing data. The majority (614/728; 84.3%) had a consistent ST segment without significant dynamic changes throughout transport, of which 521 were identified as STEMI and 93 as NSTEMI. The remaining 114 patients (15.7%) had dynamic ECG changes: 41 (36%) evolved from NSTEMI to STEMI, 40 (35.1%) changed from STEMI to NSTEMI, and 33 (28.9%) had more than one dynamic ST-segment change. Overall, 59 patients (8.1%) had a final STEMI ECG diagnosis after an initial NSTEMI ECG interpretation. Conclusion: In this study, the serial ECG system enabled the remote diagnosis of STEMI in 8.1% of patients during EMS transport following an initial NSTEMI diagnosis. Serial monitoring of dynamic changes can allow for more rapid diversion to primary percutaneous coronary intervention facilities, potentially improving patient outcomes. Further studies are needed to evaluate the clinical impact, and costs and benefits of implementing this technology.
MP029: Mobilizing citizens, decision-makers and healthcare professionals to find solutions for improving emergency care in a remote Northern emergency department: a pilot study
Authors: Fleet R. , Turgeon-Pelchat C. , Tounkara F.K. , Trottier J. , Ouellet J.
Published: June 2016

Introduction: Our national study of rural EDs showed they have limited access to CT scans, ICU, and most specialities, while Level 1 and Level 2 trauma centers are on average 300 km away. However, equivalent information on Northern/remote EDs is scarce. Objectives: This pilot study aimed to: 1) describe local access to services; and 2) mobilize citizens, decision-makers and healthcare professionals to envisage solutions to improving emergency care in a Northern/remote hospital. Methods: This descriptive, qualitative study was performed in a northern ED in Quebec. The head nurse received a prevalidated questionnaire about access to specific services, ED and patient characteristics (Objective 1). Focus groups (5) and individual interviews (11) were conducted with citizens/patients, decision-makers, physicians, nurses, paramedics, pharmacists, and mental health workers (Objective 2). Descriptive statistics are reported as means, medians and percentages for Objective 1. A thematic analysis was conducted for Objective 2. Results: Objective 1: The city (population 2875) is a mining community 962 km from Quebec City. The 2010 annual ED census was 6692. Proportions of patient visits at triage levels 1-5 were 0.2%, 3.2%, 13.4%, 25.4% and 56.7% respectively. The ED was staffed by one physician and two nurses per shift. The hospital had 24/7 access to basic X-ray and laboratory but no local access to speciality care, ICU, CT scan or ultrasound, with nearest services 28 km away. Objective 2: Analysis of qualitative data highlighted concerns for personal safety; telecommunication problems; lengthy transports; limited access to in-service training, advanced imaging, and consultants; and recruitment and retention difficulties. Solutions included pre-hospital training, telemedicine, protocols, and networking with academic centers/medical schools, North Shore colleagues, and Labrador City Hospital. Conclusion: This isolated northern ED has limited access to services. Valuable qualitative information obtained enabled us to better understand the challenges and explore solutions towards improving Northern/remote emergency care.
MP031: Synovial fluid analysis in the diagnosis of septic arthritis: comparing local data to the literature
Authors: Logan E. , Fedwick J.
Published: June 2016

Introduction: A hot, painful, swollen joint is a common presentation to the emergency department. Of the potential etiologies, septic arthritis (SA) is the most devastating. Prompt diagnosis and treatment are essential to improve outcomes. Both culture proven and clinically suspected SA are thought to have the same prognosis, with similar morbidity and mortality estimates. No clinical exam or serum lab finding has the sensitivity or specificity to diagnose or exclude SA. Instead, diagnosis relies mainly on joint aspiration and synovial fluid analysis. A synovial white blood cell count (sWBC) greater than 50,000 cells/microliter is suggestive of SA and organisms seen on gram stain or growing in culture effectively makes the diagnosis. However, culture and gram stain are positive in only 67% and 50% of cases respectively. The objective of this study was to analyze the accuracy of synovial fluid analysis in our local practice environment. Methods: All those encounters with diagnoses related to SA at four adult emergency departments in Calgary between 2013-2014 were reviewed. Hospital records were analyzed for synovial analysis, antibiotic usage and surgical procedures. Results: Of 286 encounters, 87 were determined to satisfy the definition for SA in that culture was positive, gram stain was positive or clinical findings lead to treatment with antibiotics and/or surgical intervention. Gram stain was positive in 22% of cases with cultures positive in 51% of patients. sWBC were less than 50000 in 55% of cases and less than 25000 in 24% of cases. Of 88 gram stains performed, 28% were negative but had positive culture. All positive gram stains were associated with positive cultures. Conclusion: Culture, gram stain and sWBC of patients diagnosed with SA in Calgary show differences compared with the published literature. In Calgary, the majority of SA diagnoses were made clinically. The sWBC is central to making the diagnosis. Interestingly, 55% of patients diagnosed with SA had a count less than 50,000. It remains unclear what features of history, physical exam, imaging and lab analysis lead to the diagnosis of SA in these cases. Future studies will focus on these outliers to see if a more appropriate diagnostic algorithm would be useful in Calgary. Collaboration between infectious disease specialists, orthopedics, and emergency departments guided by local data is needed to ensure accurate and timely diagnosis.
MP033: The use of femoral nerve blocks in the emergency department for hip fracture patients
Authors: Sandre A. , Thompson C. , McLeod S.L. , Borgundvaag B.
Published: June 2016

Introduction: Hip fractures affect over 30,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. Previous studies have shown that regional anesthesia is the optimal pain management strategy for hip fracture patients and has been shown to independently reduce the rate, severity and duration of delirium. However, very few emergency physicians (EPs) have the necessary training and experience to use regional anesthesia for hip fracture in the emergency department (ED). The objective of this study was to determine the number of femoral nerve blocks performed within the ED for the management of hip fracture patients. Methods: This was a retrospective chart review of patients aged 65 years and older, presenting to an academic ED (annual census 60,000) with a discharge diagnosis of hip fracture from January 1st 2014 to July 31st 2015. Results: Of the 243 hip fractures included in this study, mean (SD) age was 82.9 (8.2) years and 187 (77.0%) were female. The majority (214, 88.1%) of patients arrived to the ED by ambulance and 182 (74.9%) were categorized as CTAS 3. The most common analgesics used in the ED were intravenous (IV) hydromorphone (51.4%), IV morphine (32.1%), or dual therapy with both IV hydromorphone and IV morphine (4.9%). Femoral nerve blocks were initiated for 13 (5.3%) patients and successfully completed in 12 (4.9%) patients in the ED. Median (IQR) ED and hospital length of stay was 5.0 (3.7, 6.6) hours and 6.0 (4.1, 10.2) days, respectively. Forty-three (17.7%) patients experienced in-hospital acute delirium. Conclusion: Despite evidence to suggest regional anesthesia may be the optimal pain management strategy for hip fracture patients, the use of femoral nerve blocks in the ED remains low. Future research should attempt to elucidate barriers to use of this procedure by emergency physicians.
MP035: Point-of-care-ultrasound to diagnose appendicitis in a Canadian emergency department
Authors: Sharif S. , Skitch S. , Vlahaki D. , Healey A.
Published: June 2016

Introduction: Appendicitis is a common surgical condition that frequently requires patients to undergo diagnostic imaging. Abdominal computed tomography is the gold standard imaging technique for the diagnosis of appendicitis, but exposes patients to radiation. Ultrasound offers an alternate radiation-free imaging modality for appendicitis. However, the availability of ultrasound during off-hours is limited in many Emergency departments (EDs). Clinician performed point-of-care ultrasound (POCUS) is increasingly used by emergency physicians as a bedside tool to evaluate suspected appendicitis. The purpose of this study is to evaluate the test characteristics of emergency physician performed POCUS to diagnose appendicitis in a Canadian ED. Methods: A pragmatic, retrospective chart review was performed on all patients for whom a POCUS was performed to diagnose appendicitis at St. Joseph’s Healthcare Hamilton in Ontario from December 1, 2010 to December 4, 2015. All POCUS scans were performed by physicians with Registered Diagnostic Medical Sonographer (RDMS) credentials or resident physicians undergoing POCUS fellowship training. All scans were over-read by RDMS credentialed faculty and subject to a rigorous quality assurance (QA) process. POCUS findings and patient outcomes were reported. Results: A total of 90 patients were included in the study. 24 patients were diagnosed with appendicitis on POCUS. Ultimately, 18 were diagnosed with appendicitis through formal imaging, laparoscopy, and pathology. The sensitivity and specificity for POCUS to diagnose appendicitis was found to be 69.2% (95% CI, 48.1%-84.9%) and 90.6% (95% CI, 80.0%-96.1%) respectively. Conclusion: Bedside ultrasound is a reliable imaging modality for ruling in acute appendicitis. In cases where POCUS is negative or indeterminate for appendicitis, further imaging should be obtained as clinical suspicion warrants. The use of POCUS has the potential to reduce patient exposure to ionizing radiation and decrease the costs of obtaining CT scans, while hastening the process of achieving definitive management through earlier surgical consultation.
P005: Pre-hospital dexamethasone administration in children with croup: the Edmonton experience
Authors: Ali S. , Moodley A. , Bhattacharjee A. , Lobay K. , Chang E. , Kabaroff A. , Allain D.
Published: June 2016

Introduction: Croup is one of the most common childhood respiratory illnesses, affecting more than 80,000 Canadian children per year. Early dexamethasone administration in croup can reduce admission rates and length of stay (LOS), as well as return visits to the emergency department (ED). Pre-hospital emergency medical services (EMS) teams in Edmonton administer dexamethasone to children with croup. The objectives of this study were to (a) assess the clinical impact of pre-hospital administration of dexamethasone to children with croup and (b) compare clinical outcomes of these patients to those who did not receive their first dose of dexamethasone via the EMS providers. Methods: This study was a retrospective medical record review that included children between 6 months and 6 years of age who were brought via EMS to the Stollery Children’s Hospital ED with a final diagnosis of croup, between January 1st 2010 and December 31st 2012. Data were collected regarding pre-hospital presentation and management, ED presentation and management, ED LOS and final disposition, and patient demographics. Results: 188 patients were enrolled, 35.1% (66/188) of whom received a pre-hospital diagnosis of croup. The mean age of the participants was 32.96 months (SD±17.18). Overall, 10.6% patients (20/188) were given dexamethasone in the pre-hospital setting, while 30.3% patients (57/188) were given nebulized epinephrine by EMS. Out of the 66 patients with a pre-hospital diagnosis of croup, 10.6% (n=7) were given dexamethasone by EMS. In the ED, dexamethasone was administered to 88.3% of patients (166/188) while 56/188 participants (29.8%) received nebulized epinephrine. There was no statistically significant difference in ED LOS stay between those who received pre-hospital dexamethasone (2.6 hours, SD±1.6, n=18) and those who did not (3.3 hours, SD±2.7, n=159). The number of in-hospital epinephrine doses per patient was influenced by the administration of pre-hospital dexamethasone (p=0.010). Conclusion: Pre-hospital administration of dexamethasone likely influences the severity and short-term persistence of croup symptoms, as evidenced by less epinephrine use in the ED. Contrary to current EMS guidelines, very few patients with a pre-hospital diagnosis of croup received dexamethasone by EMS personnel. This likely represents a missed opportunity to decrease the severity of the patients’ disease.
P007: Association between serum biomarkers and frailty level in seniors with minor injurys
Authors: Allain-Boulé N. , Lebon J. , Sirois M. , Aubertin-Leheudre M. , Émond M.
Published: June 2016

Introduction: Frailty is associated with mobility & physical impairment in seniors with minor injuries. Serum biomarkers have also been suggested as potential markers of these impairments in clinical studies. No study has examined if serum biomarkers could contribute to the diagnosis of frailty in seniors with minor injuries. Objectives: To explore the association between several serum biomarkers (Ferritin, Creatinine, Vitamin D, Albumin, Glucose, Estradiol, Testosterone, Thyroid Stimulating Hormone (TSH), Insulin-Growth Factor (IGF-1) C-reactive protein (CRP)) and frailty level in seniors treated in emergency department (ED) for minor injuries. Methods: Cross-sectional study within the larger CETI cohort. It includes 142 seniors discharged home from 4 EDs after treatment of minor injuries. Their frailty status was measured by the Canadian Study of Health & Aging-Clinical Frailty Scale (CSHA-CFS). Biomarkers were obtained from blood samples. Pearson’s correlations (r) were performed to examine the relation between serum biomarkers and frailty levels. Partial correlation controlled for age and sex, were also performed. Results: Due to inclusion criteria, no patient was severely frail. Overall, these preliminary analyses seem to indicate that robust patients tended to have lower Glucose & Vitamin D levels (-0.264 ≤ r ≤ -0.230; p < 0.05), higher Estradiol (r = 0,230; p < 0.05) & Testosterone (r = 0,295; p < 0.05), while prefrail/frail patients tended to have higher Glucose & Vitamin D levels (0,235 ≤ r ≤ 0,238; p < 0.05), lower Estradiol levels (r = -0,235; p < 0.05) & more elevated Ferritin levels. Due to the small number of patients, controlling for age and sex lead to non-significant results of the most associations. Conclusion: Pre-frail/frail seniors presenting to EDs with minor injuries tend to have higher Ferritin, Glucose & Vitamin D levels as well as lower sexual hormones levels than robust individuals. Larger samples are needed in order to elucidate which biomarkers could be most useful to identify frail seniors needing clinical attention and to assess a possible association with mobility impairments in this population.
P008: Addressing chronic pain and problematic substance use of opioids in the emergency department: can a comprehensive framework for care work?
Authors: Allen M.A.
Published: June 2016

Introduction: Chronic pain and substance misuse are complex chronic illness that are subject to prejudice, misinterpretation and cultural biases. They require a broad, multi-disciplined approach if they are to be effectively managed. Barrier’s to effective care in the emergency department include our reliance on pain scales alone to effectively triage and manage chronic pain, differing philosophy’s and attitudes regarding the appropriate use of high risk pain pharmacology including opioids and confusing classifications systems used to describe pain and problematic substance use which can often lead to further stigmatization and over medicating. Methods: The charts of thirteen patients with complex pain and problematic substance use who had more than 360 visits to a regional emergency department in one year were reviewed retrospectively and data collected regarding frequency of visits and disposition after the implementation of a comprehensive pain and addiction strategy from April 2011 to August 2015. Results: In the first year of implementation there was a 70% drop in the frequency of emergency department visits. Five patients (38%) required a comprehensive pain plan. Six agreed (46%) to a direct referral to our mental health, addiction and chronic pain services. Two patients (15%) were lost to follow-up. Review of the electronic record to track patient visits to provincial emergency departments did not show an increase in visits to other facilities within the province. Review of visits in 2015 show a 97% drop in the frequency of visits. Family Physicians in the community did not report an increase in the frequency of patient visits as a direct result of the implementation of this strategy nor was there an increase in complaints to administration regarding ineffective pain management. Conclusion: Although survey numbers are low it suggests that a framework for the management of complex pain and substance use disorders can be successfully implemented in the emergency department improving timely access to appropriate management and resources for patients based on best practice to address their complex needs.
P012: Equity of care between First Nations and non-First Nations patients in Saskatoon emergency departments
Authors: Batta R. , Stempien J. , Sasbrink-Harkema M.A. , Oyedokun T.O. , Carey R.
Published: June 2016

Introduction: Studies have shown that First Nations patients have poorer health outcomes than non-First Nations patients. This has raised concerns that they receive unequal treatment from the health care system in general and the Emergency Department (ED) in particular. We sought to determine if there was such a difference and what it was so that it could be corrected. Methods: We performed a retrospective chart review to compare the care received by status First Nations and non-First Nations patients presenting to two hospital ED’s (Royal University Hospital and St. Paul’s Hospital) in Saskatoon, Saskatchewan with the chief complaint of abdominal pain and a Canadian Triage and Acuity Scale (CTAS) score of three. A total of 200 charts were reviewed (100 from each site and 100 from each group) by two medical students. One student was involved in blinding the charts; the other was responsible for analyzing the charts. Identifying information on the charts was redacted to blind the reviewer to the patient’s group during the chart review. Data extracted from each chart included time to doctor, time to analgesia given, length of stay, referral for consultation, blood work, imaging, bounce backs, reassessment, physical and history exam, and final disposition. This data will then be compared between the two population groups to find if there is equality in care given. Results: Data is currently being analyzed and will be available for presentation at CAEP 2016. Conclusion: The goal of our health care system is to provide the same level of excellent care to every patient that arrives in the ED. If care is not being provided equitably to First Nations patients this must be identified for it to be addressed. This study aimed to determine whether disparities in care exist. If they are found subsequent research could be done to determine why these differences exist while at the same time working to minimize and eliminate them for the benefit of First Nations patients.
P014: An investigation to determine if being roomed next to a psychiatric patient affects patient satisfaction and perception of care in those not being evaluated for a psychiatric complaint
Authors: Blais F.A.
Published: June 2016

Introduction: Nearly 12 million emergency department (ED) visits in the USA annually are related to a mental health and/or substance abuse condition. This is equivalent to 1 out of every 8 ED visits or 12.5 percent of all ED visits annually. States cut $5 billion in mental health services from 2009 to 2012. In the same period, the country eliminated at least 4,500 public psychiatric hospital beds. This has led to an increase in psychiatric boarding. Boarding consumes scarce ED resources and prolongs the amount of time that all patients must spend waiting for services. The aim of this study is to determine if being roomed next to a psychiatric patient affects patient satisfaction and perception of care. Methods: A survey consisting of 15 patient satisfaction questions was distributed to patients over a period of three months in the ED at a tertiary care center with >125,000 visits a year. Patients included were English-speaking adults (18 years or older) with an Emergency Severity Index of 3-5. Responses were analyzed with a chi-square across 2 groups with p-value of 0.05 considered as significant. Results: A convenience sample of 78 surveys was obtained. 40 surveys were completed by those roomed next to a patient with a psychiatric complaint and 38 surveys were completed by patients not roomed next to a patient being seen for a psychiatric complaint. For every satisfaction question asked, the patients placed away from mental health encounters gave significantly higher ratings than the patients roomed near psychiatric patients. Patients roomed next to psychiatric patients had a statistically significant decrease in satisfaction in nursing attentiveness, nursing promptness in responding to the call bell, attentiveness of the physician team, and of the overall encounter itself. All values were significant with all but one p-value being <0.01.There was no difference between the 2 groups with respect to gender, age range, reason for visit or wait time. Conclusion: This study suggests that patients being roomed next to a patient with a psychiatric complaint had significantly decreased patient satisfaction.
P015: Implementing the Canadian CT Head Rule in a community emergency department
Authors: Bock G. , Setrak R. , Freeman S.
Published: June 2016

Introduction: The Canadian CT Head Rule (‘the rule’) is widely used across the country and its use is specifically recommended by Choosing Wisely Canada. Studies in Canadian hospitals have shown appropriate declines in CT scans when decision tools have been made readily available and useable at the point of care. Research into the implementation of the Canadian CT Head Rule in particular has shown that barriers to its use include an inability to accurately recall each criteria and forgetting to attempt to apply the rule altogether. In an attempt to provide our clinicians with effective access to the rule, we modified CT requisitions and order procedures to facilitate the use of the rule for every head CT in our emergency department (ED). Methods: A quality improvement (QI) approach was used to pilot, implement, and evaluate the modified CT requisition at our hospital. Several Plan-Do-Study-Act cycles involving stakeholders in the hospital resulted in iterative changes to the requisition leading to the implemented version. The new requisition required physicians to indicate which rules or exclusion criteria were met and this was made mandatory for all head CTs ordered. Demographic data was collected on all patients presenting to the ED on age, gender, CTAS level, disposition, and length of stay. Data on which exclusion criteria were appropriate, the rules met leading to CT scans, whether each requisition was used appropriately, and whether there was a significant injury found was collected for each patient receiving a head CT after implementation. Results: In our primary outcome (% of ED visits receiving a head CT), preliminary results have demonstrated a relative reduction in head CT ordering of 10.9%. Our study at completion is powered to detect a ~10% relative change in ordering behaviour, and a Chi square of the data to date yields a P-value of 0.0147. There are no significant differences in visit volume or any of the demographics collected to date. Final results including analysis are anticipated in March, 2016. Conclusion: Preliminary results on this simple, no-cost intervention are very promising. The reduction in head CTs ordered suggests that with mandated access to an easy-to-use, well validated decision tool, ED physicians have been able to confidently defer scans that have a very low risk of having any significant injury present, reducing cost, radiation exposure, and perhaps time in department.
P019: Understanding patient perceptions of emergency department wait time publication: a mixed-methods needs assessment
Authors: Calder-Sprackman S.M. , Kwok E.S. , Bradley R. , Landreville J. , Calder L.A.
Published: June 2016

Introduction: Many emergency departments (EDs) have begun publishing wait times. This study seeks to develop an understanding of patients’ needs with respect to publishing ED wait times, which, to our knowledge, has not been described in the literature. Methods: We conducted a two-stage mixed methods study at a dual campus tertiary care academic center. First, we held focus group discussions comprising of 7 patient advocacy hospital committee members. Themes generated from focus group discussions were then utilized to create a patient survey. Focus groups were analyzed using content theme analysis. Hospital sites for survey administration were randomized and pre-assigned shifts were established to ensure a balance of weekdays, weekends, days, evenings, and overnights. All adult patients (age >18) in the waiting room were eligible, but excluded if they were directly referred to a specialty service or did not speak French or English. Survey data was analyzed using descriptive statistics. Results: We found 9 dominant focus group themes: definition of wait time, wait time posting, lack of communication, education in waiting room, patient expectations, utilization of the ED, patient behavior, physical comfort, and patient empowerment. Of the 240 patient questionnaires administered, 81.3% (195) wanted to know ED wait times before arrival to hospital and 90.8% (217) wanted ED wait times posted in the ED waiting room. The most popular choice for publishing wait times outside the ED was a website (46.7%) whereas, within the ED, patients were not particular about the specific display modality as long as times were displayed (39.6%). Overall, 76.7% (184) stated their satisfaction with the ED would be improved if wait times were posted. Conclusion: ED patients we surveyed strongly supported both the idea of having access to wait time information prior to arrival, as well as physical display of wait times in the waiting room.
P020: Paramedic comfort with providing palliative support: pre-implementation survey
Authors: Carter A. , Arab M. , Harrison M. , Goldstein J. , Jensen J. , Lecours M. , Houde K. , Downer K.
Published: June 2016

Introduction: Paramedics are sometimes called for crisis management and relief of symptoms or for patients receiving palliative care. To address the mismatch between the system protocols and resources, and patient’s goals of care, a new protocol, new medications, and an 8-hour training program Learning Essentials Approach to Palliative Care (LEAP) were implemented in our provincial EMS system. Methods: Prior to attending their training session paramedics received an invitation to complete an online survey regarding their comfort, confidence, and attitudes toward delivering palliative care. Comfort and confidence questions were scored on a 4-point Likert scale, while attitudes toward specific aspects of care were scored on a 7-point Likert scale. Descriptive statistics were calculated. Identifiers will permit linkage of these responses to a repeat survey post-implementation. Results: 188 (58%) paramedics completed the survey of the 325 who opened the link. 134 (68%) were male with a mean age of 38.5 years. 95 (50%) were primary care paramedics. The average experience as a paramedic was 12.7 years, with an estimated mean number of palliative calls per year of 9.6 each. On a 4 point scale, most (156, 83%) were comfortable with providing care to someone with palliative goals, and 130 (69.1%) were comfortable providing care without transport. Only 82 (43.6%) were confident they had the tools to deliver this care, and 76 (40.4%) were confident they could do so without transport to hospital. On a 7 point scale, paramedics disagreed with the statement “caring for dying persons is not a worthwhile experience for me”, median 7 (IQR 5-7). Paramedics also disagreed with the statement “Dying persons make me feel uneasy”, median 5 (IQR 4-6). Conclusion: Prior to the implementation of the new protocol, medications, and training, most paramedics were comfortable with the concept of providing care with palliative goals and felt that caring for dying persons is a worthwhile experience, but they were not confident that they have the tools and resources to do so. This suggests paramedics would be open to system improvements to meet an unmet healthcare need for crisis management of patients with palliative goals of care.
P022: Geriatrics care in the ED: Acute care use after the introduction of an interdisciplinary care program in Sunnybrook Health Sciences Centre's Emergency Department
Authors: Khatib N. , Charles J. , Lee J.S.
Published: June 2016

Introduction: Currently the top 5% of complex patients consume 84% of Ontario’s Hospital and Home Care costs. There is a critical need for a dynamic, person-centred care planning process for medically complex patients with real time dialogue between ED/acute care and community care providers at care transitions. A care pathway was developed in the Sunnybrook Health Science Centre’s Emergency Department using quality improvement methodology and team. The purpose of this study is to evaluate the impact of the emergency room huddle for complex care patients on emergency doctors’ perceptions of patient safety and ED efficiency measures such as department flow and delays. Methods: Intervention - Medically complex patients with frequent ED use are now automatically flagged upon registration in the Emergency Department (ED) and an ED Care Coordination team is notified by secure email: GEM nurse, ED CCAC Care Coordinator, SW, OT/PT. The GEM nurse initiates a comprehensive patient assessment in the Emergency Department right after triage and the CCAC Care Coordinator initiates a teleconference with the patient’s family physician and community Care Coordinator with the patient’s consent. Usual physician assessment is preceded and followed by an inter-professional huddle (including the EM doctor, GEM nurse, CCAC nurse and SW, OT, PT) to ensure patient's needs, goals and team recommendations are clear. Emergency doctors who have participated in an inter-professional huddle for complex care patients are contacted via a semi-structured interview and Qualtrics surveys evaluating perceptions of patient safety and ED efficiency measures such as department flow and delays. Results: Qualitative analysis of the results will be conducted and results updated at a later date. Conclusion: Safety is enhanced through better communication between ED providers, patients, their family physicians and community care providers. It is essential that the inter-professional huddle is recognized by emergency physicians as an important element of patient safety and care. An evaluation of ED doctor’s perception of the huddle will help us understand enablers and barriers to the process and inspire further quality improvements to enhance patient care.
P028: Implementation of an emergency department outpatient deep venous thrombosis treatment guideline: a quality improvement initiative
Authors: Costello L. , McGowan M. , Dounaevskai V. , Cheng A.H.
Published: June 2016

Introduction: Deep venous thrombosis (DVT) is a common diagnosis in the Emergency Department (ED). Despite evidence that Rivaroxaban is non-inferior to the low molecular weight heparin (LMWH) bridge to Warfarin approach for anticoagulation, there is still variability in physician practice. A collaborative ED-Hematology quality improvement initiative, that included a treatment guideline and increased access to a thrombosis clinic, was introduced to guide anticoagulation. Methods: A retrospective chart review of ED patients with DVT one-year pre (April 1, 2013-March 31, 2014) and one-year post (April 1, 2014-March 31, 2015) implementation of an outpatient DVT treatment guideline was conducted. Primary outcomes were percentage of patients discharged from the ED on Rivaroxaban or LMWH/Warfarin. Secondary outcomes included mean ED length of stay (ED LOS), mean number of return ED visits per patient and percentage of thrombosis clinic referrals. Balance measures included percentage of return ED visits with pulmonary embolism (PE) within one month and percentage of return ED visits with bleeding (major bleeding or clinically relevant non-major bleeding) due to anticoagulation use. Clinical and administrative data was extracted with 15% independently reviewed for inter-rater reliability. Results: 95 patients met inclusion criteria (52 patients pre and 43 post guideline implementation). The prescribing of Rivaroxaban increased from 9.6% (5/52) to 62.7% (27/43). Mean ED LOS for the Rivaroxaban group was 7.5 hours (95% CI, 5.8-9.2) versus 10.0 hours in the Warfarin group (95% CI, 8.5-11.4) [p=0.04]. The mean return ED visits for the Rivaroxaban group was 0.2 (95% CI, 0-0.3) versus 3.9 in the Warfarin group (95% CI, 3.2-4.6) [p<0.001]. The thrombosis clinic referrals increased from 29.5% (13/44) to 86.0% (37/43). There was one PE diagnosed in the Warfarin group within one month of treatment and zero in the Rivaroxaban group. There were 7.9% (5/63) return visits for bleeding in the warfarin group and 3.1% (1/32) in the Rivaroxaban group. Conclusion: By implementing an outpatient DVT treatment guideline at our academic center, we increased the prescribing of Rivaroxaban. This significantly decreased both the ED LOS and return ED visits in the Rivaroxaban group. There was also a threefold increase in referrals to a thrombosis clinic. This was all achieved without increasing patient harm.
P030: The FAN study: intranasal fentanyl and inhaled nitrous oxide for fracture reduction
Authors: Hoeffe J. , Trottier E. D. , Bailey B. , Shellshear D. , Lagacé M. , Sutter C. , Grimard G. , Cook R. , Babl F.
Published: June 2016

Introduction: Recently, intranasal (IN) fentanyl and inhaled nitrous oxide/oxygen (N2O) mixture have been increasingly used for procedural sedation and analgesia (PSA) alone or in combination. There is a lack of data on the efficacy of these combined agents. Methods: The objective was to evaluate the efficacy of IN fentanyl and N2O as PSA for the reduction of mildly-to-moderately displaced fractures and dislocations. We performed a prospective, observational cohort study between September 2014 and October 2015. Patients were recruited at CHU Sainte Justine (Montréal) and Royal Children Hospital (Melbourne, Australia). Patients aged 4 to 18 years were eligible if PSA consisted of IN fentanyl and N2O for the reduction of mildly-to-moderately displaced fractures or dislocations. Patients received at least IN fentanyl 1.5 mcg/kg (100 mcg max) and at least a 50/50% mixture of N2O with oxygen. Primary outcome was the efficacy of PSA measured by the patient assigned Facial Pain Scale-Revised (FPS-R). The Face, Legs, Activity, Cry, Consolability (FLACC) scale was also recorded. Depth of sedation was evaluated using University of Michigan Sedation Scale (UMSS). Adverse events were recorded following criteria of the Consensus Panel on Sedation Research of PERC/PECARN. Additional data concerning satisfaction or discomfort were evaluated via questionnaires, and follow-up telephone calls were made to elicit information on adverse events after discharge. Results: A total of 91 patients aged 9.7 ± 3.0 years were enrolled. There was no difference between the median FPS-R score during the procedure compared to before: Median 2 and 2 (median difference 0 [95% CI 0, 0]), respectively. The FLACC score was higher during the procedure than before: Median 4 and 0 (median difference 2 [95% CI 1, 3]). UMSS was 1 (95% CI 1, 2) during the procedure. 42 (46%) patients had adverse events, all mild: vertigo (20%), nausea (16%)]or vomiting (12%). A total of 85/88 (97%) parents and 82/85 (96%) ED physicians would want the same sedation in another procedure. Conclusion: PSA with IN fentanyl and N2O seems effective in our study, as evaluated by patient assigned FPS-R. Patients were minimally sedated. Adverse events were frequent but mild. Overall, parents and medical staff would want the same agents used in another procedure. Thus, PSA with IN fentanyl and N2O appears to be an attractive option for reduction of mildly displaced fractures or dislocations.
P032: ISAEM and the push for emergency medicine worldwide
Authors: Dashi G. , Puls H.A. , Ostervig R. , Shu O. , Huynh A. , Perinpam L.
Published: June 2016

Introduction: The International Student Association of Emergency Medicine (ISAEM) is a non-profit organization composed of medical students and student groups who believe that everyone deserves high-quality emergency care. Our aim is to promote and foster the concept, philosophy, and art of Emergency Medicine (EM). More specifically, we seek to 1) create an international network of medical students interested in EM, 2) support EM Interest Groups (EMIGs) and medical students in accomplishing their goals, 3) call for the recognition of EM as an independent specialty in countries where it does not exist, 4) help medical students learn, practice, and advance EM in countries where it is already established, and 5) carry out international projects for the benefit of medical students interested in EM. Methods: ISAEM tries to accomplish its goals primarily by connecting interested medical students and EMIGs with each other, as well as with EM professionals and organizations around the world. Additionally, we support medical students and EMIGs financially, offer them extensive benefits through a free membership, represent their local interests through our National Ambassadors, and advocate on their behalf at the local, national, and international level. Results: ISAEM’s membership base is rapidly growing and our organization is currently represented by students in over 20 countries. In areas where the specialty of EM is not yet recognized, such as in Cameroon, ISAEM helped create the first EMIG and assists students with local projects. In countries where EM is new, such as Brazil, ISAEM helps students discover, explore, and advance this specialty. In countries where EM is thriving, like Canada, ISAEM offers students academic and personal opportunities to advance their careers and the specialty of EM internationally. Additionally, with the help of EM leaders worldwide, ISAEM has recently launched the FOAMed (Free Open Access Medical education) Translation Project and the International Observership Program. In the future, we aim to offer students international research, clinical, and mentorship programs, as well as more financial support. Conclusion: ISAEM is the international voice of medical student interested in promoting access to and expertise in emergency medical services worldwide. Through international collaboration, we hope to create an extensive network that will benefit medical students and the specialty of Emergency Medicine for many years to come.
P034: Réanimation cardio-pulmonaire sans période de “no-flow”: un nouveau dispositif
Authors: Deslandes J.
Published: June 2016

Introduction: La b-card (Boussignac Cardiac Arrest Resuscitation Device) est un dispositif permettant d'assurer une oxygénation passive continue lors des manoeuvres de compressions/décompressions réalisées dans le cadre d'un arrêt cardiaque. Ce dispositif fonctionne par création d'une valve virtuelle induite par l'accélération d'un débit d'oxygéne via des micro-canalicules. Cette valve est censée s'opposer aux flux de gaz entrant et sortant de la cage thoracique lors des compressions/décompressions. Elle permettrait d'obtenir une pression positive intra thoracique lors des compressions, et une pression intra thoracique négative lors des décompressions. L'expérimentation conduite a pour but de mesurer la pression statique créée dans le dispositif par le débit d'oxygène, ainsi que les valeurs de pressions et de flux générés en intra thoracique. Methods: La b-card est almimentée par un débit d'oxygène de 15 L/min, et connectée via différentes interfaces à un poumon test pourvu de capteurs:

-Capteur de pression des voies aériennes (PAW en cm H2O).

-Capteur de débit au niveau des voies aériennes.

-Capteur de pression “intra thoracique” (PIT max et min; et Pression Expiratoire Intra Thoracique).

Les mesures sonrt effectuées sans b-card, puis avec b-card connectée à un masque facial, un masque laryngé, une sonde trachéale.

Results: La pression “statique”, celle de la valve virtuelle, mesurée au niveau de la b-card reste stable à 6 cm d'H2O, sous un débit de 15 L/min. Elle permet une résistance à hauteur de cette valeur aux flux de gaz entrant ou sortant du thorax expérimental en fonction des compressions/décompressions. Les pressions intra thoraciques positives mesurées lors des compressions restent équivalentes autour de 25 à 30 cm H2O, et ce quelle que soit l'interface utilisée. Les pressions intra thoraciques négatives mesurées lors des décompressions restent équivalentes autour de 10 à 15 cm d'H2O, et ce quelle que soit l'interface utilisée. Conclusion: Les pressions intra thoraciques obtenues en associant une oxygénation passive par la b-card à des compressions/décompressions continues permettent d'assurer une ventilation efficace et synchrone. Les pressions mesurées au niveau du dispositif sont constamment inférieures à la pression d'ouverture moyenne oesophagienne, ce qui éviterait toute insufflation gastrique.
P035: Optimization of indirect pressure to temporize life-threatening haemorrhage: a simulation study
Authors: Douma M.J. , Dochartiagh D.O.
Published: June 2016

Introduction: Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, such as external aortic compression which has been identified as an immediately applicable maneuver to address the leading cause of battlefield mortality: junctional hemorrhage. However, it is currently unclear how to optimize this technique. Methods: This prospective, block-randomized, cross-over simulation study of compression optimization was performed on a model of central vessel compression that recorded weight (lbs) and pressure (mmHg). Forty participants simulated external aortic compression on the ground as well as a stretcher with and without a backboard. Participants were blinded to compression weight and pressure, as well as the purpose of the study, to minimize preparation bias. Manoeuvres were performed in alternating order to control for skill acquisition and fatigue. Scripted instructions were followed to compress with 1 then 2 hands, and to apply “sustainable effort” and then “maximal effort”. Results: The greater the compressor's bodyweight the greater their mean compression (Pearson’s correlation 0.9342). Using one-hand, a mean of 28% participant bodyweight (95%CI, 26% - 30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased rescuer bodyweight transmission by 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p<0.001). Adding a backboard increased transmission of rescuer bodyweight 7%-15% (p<0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4%-9% (p < 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p <0.001). Conclusion: Efficacy is maximized with larger-mass, two hands, and compression on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). This study demonstrates the feasibility of indirect pressure as a potential temporizing measure for life-threatening haemorrhage not amenable to direct compression.