bluuebunny/crossref_metadata_2025 huggingface dataset:
P115: Bounceback reports-improving patient care
Authors: Pinto F. , B-Lajoie M.
Published: May 2018

Introduction: Seeking patient outcome feedback (POF), defined as obtaining information on a patients clinical course beyond ones care, is crucial to the learning process. However, the lack of POF is a major pitfall of emergency medicine. Emergency department (ED) bouncebacks, which are characterized as patients with unplanned returns to the ED after being discharged, are an important type of POF to study because they represent a potential misdiagnosis or mismanagement and can highlight areas for physician self-improvement. Currently, most hospitals do not relay details about ED bouncebacks back to the treating physician, unless a grave error occurred. This studys purpose is to provide weekly reports to all physicians in the ED on patients who have unplanned returns within 7 days of discharge from the ED, and evaluate the impact this has on the physicians practice on seeking POF. Methods: A new weekly report was distributed to physicians working at an academic hospital outlining the patients who have returned within 7 days of discharge from the ED, their new presenting complaint and final disposition. An online survey was also administered to all ED staff evaluating the amount of POF they sought pre and post report, and their attitude towards the new reports. Results: 22 responses were received, for a response rate of 85%. The majority of respondents follow the reports (73%) and actively seek POF by looking up patients charts and results(70%). Additionally, 58% state that they seek POF more often since receiving these reports, for both the bouncebacks and their other patients. Furthermore, 37% claimed that the reports helped improve the appropriateness of their referrals and 32% stated it helped increase their confidence in their clinical practice. The majority of physicians (87%) found the reports to be helpful and would like to continue receiving it. Conclusion: Weekly bounceback reports are a high-yield tool for increasing POF sought in the ED and have benefits for both the physician and the department as a whole. They can be used to not only identify patients who may have had an error in their management, but also help to improve physicians’ clinical skills by encouraging and enabling follow-up of patients they managed. Thus, bounceback reports are a valuable tool to provide to physicians and should be considered by ED Departments.
P116: A randomized cross-over trial of conventional bimanual versus single elbow (Koch) chest compression quality in a height-restricted aeromedical helicopter
Authors: Pompa N. , O’Dochartaigh D. , Douma M. J. , Jaggi P. , Ryan S. , MacKenzie M.
Published: May 2018

Introduction: Aeromedical helicopters and fixed wing aircraft are used across Canada to transfer patients to definitive care. Given height limitation in aeromedical transport, CPR performance can be affected. An adapted manual compression technique has been proposed by H. Koch (pron. Cook) that uses the elbow to compress the sternum rather than the conventional hand. This preliminary study evaluated the quality of Koch compressions versus conventional bimanual compressions. Methods: Paramedics (5), registered nurses (3) and a physician (1) were recruited. Each participant performed a 2 minute cycle of each technique, were randomized to determine which technique was performed first, and rested 5 minutes between compression cycles. A Resusci Anne SkillReporter manikin atop a stretcher in a BK117 helicopter was used. The compressors performed without feedback or prompting. Outcomes include compression rate, depth, recoil, and fatigue. Results: The mean conventional compression rate was (bpm) 118 +/− 13 versus 111 +/− 10 in the Koch scenario (p=0.02) (target 100 to 120). Mean conventional compression depth (mm) was 44 +/− 9 versus 49 +/− 7 in the Koch scenario (p=0.01) (target 50 to 60). The mean percentage of compressions with complete release in the conventional scenario was 86 +/− 20 versus 84 +/− 22 in the Koch scenario (p=0.9) (target 100%). Using a Modified Borg Scale of 1 to 10, mean provider fatigue after conventional CPR was 7 (+/− 1.6) versus 3 (+/− 1.2) using Koch technique (p<0.001). On average, Koch technique improved the percentage of compressions at target rate by 26%, the percentage at correct depth by 9%, overall compression quality score by 13% and were more less fatiguing. Conclusion: Using an elbow in a height-restricted environment improved compression depth and reduced provider fatigue. From our limited data, Koch compressions appear to improve compression quality. Further study and external validation are required.
P118: Pulmonary Embolism Severity Index (PESI) score as a predictor for readmission in acute pulmonary embolism in emergency department?
Authors: Prajapati D. , Suryanarayan D. , Lang E. S.
Published: May 2018

Introduction: Pulmonary Embolism (PE) management in Emergency Department (ED) confers a substantial cost burden representing opportunities for improvements in decision-making. The Pulmonary Embolism Severity Index (PESI) is a validated tool to prognosticate patients with PE supporting admit versus (vs.) discharge decisions from the ED. Despite existing evidence, PESI is under-used in patients with PE. We sought to evaluate PESI scores and patient disposition from 4 EDs within Calgary to determine discordance between them and the effect of the discordance on readmission and mortality. Methods: Retrospective review of adult patients 18 years, diagnosed with PE between January-June 2016 at 4 EDs in Calgary Health Region. Patients were divided into high-risk PESI (score>85) and low-risk PESI (score 0-85). Chi-Square (2) test was used for comparison between the groups. Primary outcome measure was rate of discordance between PESI risk and disposition decision and identify factors driving the discordance. Secondary outcome measures included comparing 30-day readmission rate, 30-day and 90-day mortality between the discordant PESI groups. Results: 365 patients were diagnosed with PE in the study period with 60% being admitted and 40% discharged. The median PESI score in admitted patients was 85 (26-172) vs. 68 (20-163) in discharged patients. 51% of admitted patients had a low-risk PESI score and 24% of the discharged patients were high-risk PESI. 30-day readmission rate was 22.9% vs 5.3% (p=0.002) in discharged patients with high-risk PESI vs. discharged patients with low-risk PESI. Hypoxemia was the most common (62%) justification for admission in low-risk PESI groups. Among discharged patients we noted an 8.6% 90-day mortality in the high-risk vs. 0% in the low-risk PESI groups. Conclusion: Discharging a PE patient from the ED with a high PESI score carries a significant risk of ED revisit and readmission. Hypoxia was the reason for admission in majority of low risk PE patients.
P120: Rapid hepatitis C virus screening and diagnostic testing for high-risk patients in an urban emergency department: a pilot project
Authors: Ragan K. , Pandya A. , Collins N. , Swain M. , Holotnak T.
Published: May 2018

Introduction: Hepatitis C virus (HCV) infection represents a significant public health problem in Canada and it is estimated that nearly half of individuals with chronic hepatitis C infection are unaware of their disease status. Previous studies of urban emergency department (ED) based screening programs have shown a prevalence ranging from 7.3 to 26% in high risk patients presenting to the ED . The advent of new treatment regimens with high rates of virologic cure strengthens the case for identifying the optimal setting for screening and testing individuals who may benefit from treatment. The proposed pilot project of ED-based screening for hepatitis C virus will aim to determine the prevalence of undiagnosed HCV infection and to link patients with chronic HCV infection to appropriate specialized follow-up care. Methods: We will be conducting a prospective cohort study of patients presenting to an urban emergency department between March and May 2018. Patients will be screened using high risk criteria for HCV infection as per national guidelines. Eligible patients will be offered and consented for a rapid point of care antibody test. Individuals with a positive antibody screen will have confirmatory testing and be linked to hepatology follow-up. The primary outcome will be the prevalence of hepatitis C virus among tested patients. Secondary outcomes will include the proportion of high risk patients without a primary care MD or access to alternate care settings where screening may occur, as well as the proportion of HCV-positive patients who are successfully linked to care. Results: We expect to screen approximately 2000 participants during the study period leading to an estimated 400 rapid antibody tests. Based on published results from other centres, we estimate that a significant proportion of screened patients will test positive for chronic HCV infection ( > 10%). Descriptive analyses will be performed for all variables using proportions with 95% confidence intervals. Conclusion: To our knowledge, no emergency department in Canada has undertaken protocoled HCV screening using rapid antibody testing in the ED. Results will inform the future development of integrated ED-based screening programs in novel settings more likely to be accessed by the at-risk population. Linking patients with chronic HCV infection to appropriate care will decrease the number of individuals developing HCV-related cirrhosis and hepatocellular carcinoma, thereby improving patient outcomes and reducing the future impact on our health care system.
P122: Ready for the story? A mixed methods systematic review of factors that influence handovers between prehospital personnel and emergency department nurses receiving patients arriving by ambulance
Authors: Reay G. , Norris J. , Nowell L. , Abraham J. , Hayden A. , Yokom K. , Lazarenko G. , Lang E. S.
Published: May 2018

Introduction: Safe and efficient handovers between emergency medical services (EMS) practitioners and emergency nurses are vital as poor transitions may lead to loss of information and place patients at risk for adverse events. We conducted a mixed methods systematic review to a) examine factors that disrupt or improve handovers from EMS practitioners to emergency department nurses, and b) investigate the effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. Methods: We searched electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); grey literature (grey literature databases, organization websites, querying experts in emergency medicine); and reference lists of the included studies. Citation tracking was conducted for the included studies. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the Joanna Briggs Institute Critic Appraisal Checklist for Qualitative Research. Narrative and thematic synthesis were conducted to integrate and explore relationships within the data. Results: Twenty-two studies were included in this review from the 6150 records initially retrieved. Our analysis suggests that qualitative, quantitative, and mixed methods research approaches have been utilized to explore handovers. Studies (n=11) have predominantly explored existing patterns of handovers focusing on barriers and facilitators. Interventions (e.g. multimedia transmission of pre-hospital information, tailored e-learning program) were investigated in five studies. Results suggest that lack of formal handover training, workflow interruptions, workload, and strained working relationships between EMS and nursing are perceived threats to optimal handovers. Conclusion: The findings from this review can inform the development of handover interventions and contribute to a more rigorous approach to researching handovers between EMS practitioners and emergency nurses. Furthermore, there is a need for studies in which specific interventions to optimize handovers are examined.
P123: Mental practice for technical skills training in emergency medicine: a scoping review
Authors: Riggs J. R. , Hicks C.
Published: May 2018

Introduction: Emergency physicians must achieve and maintain competence in numerous procedural skills, many of which are high stakes, time dependent, and used infrequently in clinical practice. Mental practice (MP) is the systematic use of mental imagery to see and feel an action in ones imagination without engaging in actual physical movement, and has been shown to enhance skill acquisition and performance in music and athletics. In this scoping review, we describe the utility and effectiveness of MP as a tool for procedural skill acquisition in medicine. Methods: An electronic search of MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, Open Grey, Conference Proceedings Index, ProQuest Dissertations and Theses and Google Scholar was conducted. Included studies evaluated MP for learning medically related technical skills using any method of mental training (script memorization, hypo-therapy, psychotherapy). Two independent reviewers screened articles for inclusion, and data was extracted using a standardized tool. Results: Our search returned 2028 results, of which 61 were eligible for inclusion. Forty-three studies evaluated MP interventions for technical skill development. Of these, 69.6% focused on minimally invasive surgical skills. The most common outcome measure was quantitative evaluation of skill via observer-scored checklist (69.6%). Other outcomes included stress, time to task completion, and haptic and movement data from surgical simulators. 82.6% of studies demonstrated a positive effect of MP on skill acquisition or performance. The quality of the trials was modest, and only 34.7% of published work provided clear detail on specific MP strategies. Conclusion: MP is an effective tool for procedural skills training. Areas outside of minimally invasive surgery are under-represented, and more data is needed on MP for rare or emergent procedures that typify emergency care. The minority of studies reviewed reported methods for developing and validating MP interventions in sufficient detail, a practice that should be adopted in future trials.
P130: Cumulative daily boarding time: a new way to measure emergency department congestion and hospital-wide flow
Authors: Salehi L. , Jegatheeswaran V. , Phalpher P. , Valani R. , Mercuri M.
Published: May 2018

Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is one of the major contributors to ED overcrowding, and an indicator of hospital-wide deficiencies in capacity and flow. Most indicators of ED overcrowding have measured either counts or percentages of patient subgroups (e.g. number/percentage of patients waiting in triage or number/percentage of admitted patients as compared to full ED census), or specific process time intervals related to patient movement through the hospital (e.g. Physician to Initial Assessment (PIA) time or total ED Length of Stay (EDLOS)). We sought to 1) devise an alternative measure of ED overcrowding that captured the dynamic and disproportionate resource utilization of admitted versus non-admitted patients in the ED, and to 2) determine the association of this measure with selected ED quality metrics for non-admitted patients. Methods: We conducted a retrospective multi-centre observational study at three very high-volume community hospitals in the Greater Toronto Area. Data on all patients visiting the ED during the period between January 1, 2015 and December 31, 2016 were included in the study. We calculated the total daily cumulative boarding time - or time to bed (TTB) - for each day of the study duration. The daily cumulative TTB was calculated as the time from decision to admit to transfer from the ED for all admitted patients within a 24-hour period. We conducted linear regression analysis to determine the association between our measured daily cumulative TTB and daily median and 90th percentile PIA and EDLOS times for non-admitted patients. Results: Preliminary results for 2015 indicate a total cumulative TTB time ranging from 50,973 hours to 191,093 patient-hours for the year, with daily mean cumulative TTB ranging from 140 524 patient-hours/day among the three hospitals. In all three hospitals, there was a statistically significant (p<0.01) positive association between daily cumulative TTB and both median and 90th percentile PIA times for all patients, and median EDLOS times for non-admitted CTAS 1 -3 patients. There was a statistically significant (p<0.05) positive association between daily cumulative TTB and 90th percentile EDLOS for non-admitted CTAS 1-3 patients in two of the three hospitals, with the third hospital showing a positive but non-significant association. Conclusion: Bed boarding constitutes a significant resource cost for EDs, and has a negative impact on timeliness of ED care for the general ED population, particularly more complex (CTAS 1-3) non-admitted patients.
P131: Antimicrobial stewardship and best practices for the treatment of STIs in ED sexual assault patients
Authors: Sampsel K. , Leach T. , Muldoon K. , Drumm A. , Blaskovits F. , Heimerl M.
Published: May 2018

Introduction: It is assumed that sexual assault cases presenting at Emergency Departments (ED) are frequently lost to follow-up and should be considered an eligible population for presumptive antimicrobial treatment of sexual transmitted infections (STIs) at initial assessment without lab confirmation. With the growing burden of antibiotic resistance, antimicrobial stewardship guidelines caution against this practice. Among sexual assault cases, our study evaluated STI prevalence, follow-up and retention patterns, and described the prevalence of STI presumptive treatment. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital is the only program in Ottawa offering emergency and forensic care for survivors of sexual assault and domestic violence. Descriptive statistics were used to summarize information on demographics, clinical presentation, STI testing and results using data from the SAPACP case registry (January 1 - December 31, 2015). Results: Among the 406 patients seen by the SAPACP, there were 262 (64.5%) sexual assault cases that were included in this analysis. STI testing was completed for 209 (79.8%) patients at the initial visit, 90 (43.1%) completed via urine nucleic acid testing (NAAT), 140 (67.0%) via culture swab and 20 (9.6%) via both. Laboratory results detected no cases of gonorrhea, 8 (3.8%) cases of chlamydia, 33(15.8%) cases of bacterial vaginosis (BV), 17 (8.1%) cases of yeast vaginitis and 16 (7.7%) indeterminate testing results. Antimicrobial STI presumptive treatment was given to 12 (5.7%) patients at the time of their initial visit prior to lab confirmation. Patient follow-up occurred in 172 (82.3%) patients, with all chlamydia cases treated. Of the 37 (17.7%) patients lost to follow up, 9 were positive for BV, 1 was positive for yeast and 10 were indeterminate, all of which may be underlying vaginal flora. Follow up testing/test of cure was completed in 91 (52.9%) of patients, with 4 (2.3%) positive results, all of which were BV. Conclusion: In our ED, up to 15.8% of sexual assault patients had at least one laboratory confirmed STI and over 80% of all patients returned for follow-up. Our results show that it is safe and effective to only treat STI screen positive cases at follow-up, reducing the frequency of presumptive antimicrobial STI treatment. Benefits of this strategy include decreased patient side effects, cost savings and better antimicrobial stewardship.
P133: Meteorological predictors of epidemic orthopedic trauma in Calgary
Authors: Schweitzer C. , Wang D. , Lang E. S.
Published: May 2018

Introduction: On March 16 2017, emergency departments and urgent care centres (collectively, EDs) in Calgary saw 3 times the number of fall-related ED visits, and 8 times the number of ED orthopedic consultations and admissions than the daily average for March 2014-2016. Fall-related injuries have significant associated morbidity and burden of disease, as well as cost to the health care system, caregivers and society. The purpose of this study was to use regression analysis to generate best fit models and identify weather and temporal variables which predict the frequency of fall-related ED visits, orthopedic consultations and admissions in winter (November-March). Methods: Daily number of ED visits, orthopedic consults, and orthopedic admissions for presenting complaint of Lower Extremity Injury, Upper Extremity Injury, or with an ED diagnosis of Fracture or Fall, were obtained for winter months from November 1 2013 to March 31 2017 from the Alberta Health Services ED database. Weather data was obtained from Environment Canada. Linear and multiple regression were performed to evaluate the predictive value of individual weather and temporal parameters, and derive the best-fitting model to predict the number of ED visits, orthopedic consultations, and orthopedic admissions. Results: Individual predictive factors (p<0.05) were month, temperature, overnight temperature drop from >0C to <0C, day of the week, amount of snow on the ground at 05:00, post-chinook day (chinooks are a warm winter wind in Calgary that can cause large temperature swings), maximum wind gust speed, and presence of precipitation. The best-fit multivariable models predicting fall-related ED visits (F-stat=15.36, R2=0.171), orthopedic consults (F-stat=6.369, R2=0.048), and orthopedic admissions (F-stat=8.658, R2=0.126) were statistically significant (probability of F-statistics all <0.0001). Conclusion: This study is, to the best of our knowledge, the first to use multiple regression to compute models using weather and temporal variables that can predict fall-related ED visits, orthopedic consults and admissions. This information could be used to alert the population regarding an increased fall and fracture risk ahead of the weather occurrence, as well as municipal snow and ice clearing services, who may be able to mitigate that risk. The ability to predict the frequency of fall-related injuries could enable EDs, EMS, orthopedic services, and hospitals to adjust resource and staffing allocation in anticipation of increases in fall-related injuries.
P134: Escape game as a theatre-based simulation for teamwork skills training in undergraduate medical education
Authors: Seto A. V.
Published: May 2018

Introduction: Teamwork skills are essential in emergency presentations. When training medical students to manage acute care cases, simulation is frequently the educational tool. However, simulation content is often medically-focused, and post-simulation debriefs may not prioritize discussion of teamwork skills, as time is limited. Furthermore, debriefing both medical and teamwork aspects of a case may add to the learners cognitive load. This innovation uses an escape game as a non-clinical simulation to gamify teamwork skills training, with a focus on the collaborator CanMEDS role. In the entertainment industry, escape games are activities where teams solve a series of puzzles together to ultimately escape a room. Methods: 2 groups of 5 second-year medical students piloted the escape game, created within a simulation theatre, designed to surface teamwork competencies under the four University of Calgary Team Scheme domains (adapted from CIHCs National Interprofessional Competency Framework and TeamSTEPPS): Leadership/Membership, Communication, Situation Monitoring, and Collaborative Decision-Making/Mutual Support. During the game, facilitators noted examples of students strengths and challenges in demonstrating teamwork competencies. Post-game, a debrief and written reflective exercise enabled students to analyze successes and challenges in demonstrating teamwork competencies, propose solutions to teamwork challenges, and write 3 goals to improve teamwork skills. All competencies listed under each Team Scheme domain represented themes used in a thematic analysis to uncover students reported teamwork challenges. Results: Each escape game is a 30-minute teamwork activity where 5 students collaborate to complete 8 puzzles, which do not require medical knowledge, in order to win. Briefing is scheduled for 15-minutes, whereas post-game debriefing and reflection is 45-minutes. Conclusion: Escape games can highlight strengths and challenges in teamwork and collaboration amongst second-year medical students. Every competency under the Team Scheme domains was highlighted by the escape game pilots, touching on both strengths and challenges, for which students demonstrated, debriefed, and reflected upon. Students self-documented teamwork challenges include issues surrounding task-focused, closed-loop communication, and frequent reassessments. Advantages of this innovation include its use as a learning progression towards acute care simulations, portability and affordability, potential interprofessional use, and customizability. Additional training time may be required to orient facilitators to this atypical simulation. The escape game will launch in MDCN490 for second-year medical students and is scheduled prior to their acute care simulations. Further teamwork challenges identified at that time will help inform teamwork curriculum development for year 3.
P139: How available is availability bias? Examining factors that influence diagnostic error
Authors: Sherbino J. , Monteiro S. , Ilgen J. , Hayden E. , Howey E. , Norman G.
Published: May 2018

Introduction: Cognitive bias is often cited as an explanation for diagnostic errors. Of the numerous cognitive biases currently discussed in the literature, availability bias, defined as the current case reminds you of a recent similar example is most well-known. Despite the ubiquity of cognitive biases in medical and popular literature, there is surprisingly little evidence to substantiate these claims. The present study sought to measure the influence of availability bias and identify contributing factors that may increase susceptibility to the influence of a recent similar case. Methods: To investigate the role of prior examples and category priming on diagnostic error at different levels of expertise, we devised a 2 phase experiment. The experimental intervention was in a validation phase preceding the test, where participants were asked to verify a diagnosis which was either i) representative of Diagnosis A, and similar to a test case, ii) representative of Diagnosis A and dissimilar to a test case, iii) representative of Diagnosis B and similar to a test case. The test phase consisted of 8 written cases, each with two approximately equally likely diagnoses(A or B). Each participant verified 2 cases from each condition, for a total of 6. They then diagnosed all 8 test cases; the remaining 2 test cases had no prior example. All cases were counterbalanced across conditions. Comparison between Condition i) and ii) and no prior showed effect of prior exemplar; comparison between iii) and no prior showed effect of category priming. Because cases were designed so that both Diagnosis A and B were likely, overall accuracy was measured as the sum of proportion of cases in which either was selected. Subjects were emergency medicine staff (n=40), residents (n=39) and medical students (n=32) from McMaster University, University of Washington, and Harvard Medical School. Results: Overall, staff had an accuracy (A + B) of 98%, residents 98% and students 85% (F=35.6,p<.0001). For residents and staff there was no effect of condition (all mean accuracies 97% to 100%); for students there was a clear effect of category priming, with accuracy of 84% for i), 87% for ii) and 94% for iii) but only 73% for the no prime condition (Interaction F= 3.54, p<.002) Conclusion: Although prior research has shown substantial biasing effects of availability, primarily in cases requiring visual diagnosis, the present study has shown such effects only for novices (medical students). Possible explanations need to be explored. Nevertheless, our study shows that with increasing expertise, availability may not be a source of error.
P140: Risk factors for adverse outcomes in hyperglycemic patients presenting to the emergency department: a systematic review
Authors: Siddiqi L. , Van Aarsen K. , Iansavitchene A. , Yan J. W.
Published: May 2018

Introduction: Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes such as recurrent ED visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (< 25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level > 20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate > 110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up.
P146: Organ and tissue donation from poisoned patients in the emergency department: a Canadian perspective
Authors: Staple L. J. , MacIntyre J. , Murphy N. G. , Beed S. , LeBlanc C.
Published: May 2018

Introduction: Screening for organ and tissue donation is an essential skill for emergency physicians. In 2015, 4564 individuals were on a waiting list for organ transplant and 242 died while waiting. As Canadas donation rates are less than half that of other comparable countries, it is crucial to ensure we are identifying all potential donors. Patients deceased from poisoning are a source that may not be considered for referral as often as those who die from other causes. This study aims to identify if patients dying from poisoning represent an under-referred group and determine what physician characteristics influence referral decisions. Methods: In this cross-sectional unidirectional survey study, physician members of the Canadian Association of Emergency Physicians were invited to participate. Participants were presented with 20 organ donation scenarios that included poisoned and non-poisoned deaths, as well as one ideal scenario for organ or tissue donation used for comparison. Participants were unaware of the objective to explore donation in the context of poisoning deaths. Following the organ donation scenarios, a range of follow-up questions and demographics were included to explore factors influencing the decision to refer or not refer for organ or tissue donation. Results were reported descriptively and associations between physician characteristics and decisions to refer were assessed using odds ratios and 95% confidence intervals. Results: 208/2058 (10.1%) physicians participated. 25% did not refer in scenarios involving a drug overdose (n=71). Specific poisonings commonly triggering the decision to not refer included palliative care medications (n=34, 18%), acetaminophen (n=42, 22%), chemical exposure (n=48, 27%) and organophosphates (n=87, 48%). Factors associated with an increased likelihood to refer potential donors following overdose included previous organ and tissue donation training (OR=2.6), having referred in the past (OR=4.3), available donation support (OR=3.9), greater than 10 years of service (OR=2.1), large urban center (OR=3.8), holding emergency medicine certification (OR=3.6), male gender (OR=2.2, CI), and having indicated a desire to be a donor on government identification (OR=5.8). Conclusion: Scenarios involving drug overdoses were associated with under-referral for organ and tissue donation. As poisoning is not a contraindication for referral, this represents a potential source of donors. By examining characteristics that put clinicians at risk for under-referral of organ or tissue donors, becoming aware of potential biases, improving transplant knowledge bases, and implementing support and training programs for the organ and tissue donation processes, we have the opportunity to improve these rates and reduce morbidity and mortality for Canadians requiring organ or tissue donation.
P149: Do patients presenting to the emergency department with a mental health crisis have access to community healthcare resources?
Authors: Thompson C. , McLeod S. , Sandre A. , Borgundvaag B.
Published: May 2018

Introduction: The emergency department (ED) is often the first point of access to the health care system for patients with an acute mental health crisis. Outpatient resources are limited, typically do not operate after hours, and patients and their families often lack sufficient information on where and how to access mental health services within their communities. The objective of this study was to determine which community healthcare resources patients attempted to access for their mental health condition prior to presenting to the ED. Methods: Between April 2016 to June 2017, a convenience sample of adult ( 18 years) patients presenting to an academic ED (annual census 65,000) with a mental health complaint were invited to complete a 23-item, paper-based survey. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 200 patients who completed the survey, mean (SD) age was 37 (16) years and 96 (48%) were male. 20 (10%) patients were brought to the ED involuntarily by police services. 175 (88%) had been previously diagnosed with a mental health condition, the most common being depression and/or anxiety (n=134, 67%). 47 (24%) patients indicated they were currently only connected to a primary care provider, while 94 (47%) patients indicated they had existing relationships with multiple mental healthcare providers. 117 (59%) patients attempted to see an alternative healthcare provider prior to coming to the ED. 78 (39%) patients had a pending scheduled appointment with a healthcare provider for their mental health condition, 44 (56%) of which were within 7 days of their ED visit, but chose to seek care in the ED. 38 (19%) patients either had a referral with no appointment date set, or had an impending mental health appointment scheduled more than 30 days from their ED visit. Conclusion: These findings suggest that most patients seeking ED care during a mental health crisis do so despite being connected to alternative healthcare providers and outpatient services. Future studies should attempt to determine reasons why patients with mental health conditions seek care in the ED, and examine barriers to mental health care in the community and outpatient setting.
P151: Occupational therapy in the emergency department: sustaining results
Authors: Trenholm J.
Published: May 2018

Introduction: An emergency department visit may represent a sentinel event for someone who is older and frail, signalling a slide into dependence and functional decline. The gold standard for the treatment of frail older adults is a comprehensive geriatric assessment, involving consideration of multiple domains including mobility and function in activities of daily living. Despite this, when a chart audit was conducted in a Canadian metropolitan emergency department, none of the patients age 65 and older had a documented assessment of their function or mobility. In response, an occupational therapy program was implemented. The goals of this program were to reduce the number of unnecessary hospital admissions related to patient functional impairments, and to increase function, safety, and independence for patients upon discharge from the emergency department. Methods: The pilot project, which was completed in 2013, was evaluated using a mixed methods approach. Positive patient outcomes at that time included a reduction in avoidable admissions and better support for patients upon discharge from the emergency department. A survey of emergency department staff indicated that occupational therapy consultation added value to the diagnostic and discharge planning processes. However, due to changes in administrative priorities, several service redesigns were required. Multiple PDSA cycles were completed, and the development of a logic model guided and focused program development. Results: A reassessment of program objectives was conducted using 2015 data, which found that the number of patients seen by the occupational therapist remained the same, as did the percentage of patients discharged with support of occupational therapy intervention, such as provision of adaptive equipment or referral to community rehabilitation referrals. The percentage of patients discharged due to occupational therapy as a primary contributing factor rose slightly, and staff satisfaction with the program remained high. Conclusion: This evaluation proves that the provision of occupational therapy services in the emergency department is sustainable, benefits patients, and can be incorporated into the emergency department workflow and culture.
P152: Point of care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times
Authors: Myslik F. , Vandelinde J. , Leeper R. , Hilsden R. , Thompson D. , Koichopolos J.
Published: May 2018

Introduction: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making many emergency medicine physicians have pursued specialized training to perform point of care biliary ultrasound in the emergency department (BUSED). The purpose of this study was to determine the usefulness of BUSED in predicting the need for surgical consultation and intervention for biliary disease. Methods: A retrospective study of 283 consecutive patients visiting the emergency department who received a BUSED scan from December 1, 2016 to July 16, 2017. Physician interpretations of the BUSED scans were collected from the electronic image storage and interpretation system. Additional data was collected from the electronic health record including lab values, the subsequent use of diagnostic imaging, and outcomes data including disposition, surgical consultation or intervention, and 28 day follow up for representation or complication. Descriptive statistics and logistic regression were performed. Results: Of the patients who received a biliary POCUS scan, 29% were referred to general surgery, and 43% of those referred proceeded to eventual cholecystectomy. Factors found to be independently predictive of surgical intervention on point of care BUSED scans included presence of gall stones (OR 13.01, 95%CI 5.02 to 27.1) and increased gallbladder wall thickness (OR 6.01, 95%CI 1.7 to 11.1). A total of 30% of patients receiving BUSED required at least one additional, radiology based imaging test (CT or diagnostic US). Average emergency department length of stay was substantially longer for those who required additional imaging as compared to those who were able to be diagnosed by BUSED alone (16.1 versus 5.2 hours, 10.9 hours 95%CI 10.6 11.2, p<0.05) . Conclusion: Point of care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gall stones and increased gall bladder wall thickness are highly predictive of the need for surgical intervention. Future, prospective studies are warranted to determine if point of care sonography is sufficient to proceed to surgery in select cases of uncomplicated biliary disease.
P154: Exploring health care connections and transitions in care for patients presenting to emergency departments with acute wheezing illnesses
Authors: Rowe B. H. , Villa-Roel C. , Bhutani M. , Couperthwaite S. , Runham N.
Published: May 2018

Introduction: Asthma and/or chronic obstructive pulmonary disease (COPD) exacerbations often result in emergency department (ED) visits. This study examined the health-related personnel providing regular care to patients with asthma and/or COPD, as well as, explored the coordination of care between the ED and outpatient settings. Methods: Descriptive cross-sectional examination of patients presenting with asthma and/or COPD exacerbations to two EDs in Edmonton between August and December 2017. Using patient interview methods information on demographics, established health care connections and health system use was collected; information on consultations, disposition and referrals was collected through chart review methods. Results: A total of 50 patients were recruited (14 patients with asthma and 36 patients with COPD). Most of the patients with asthma were female (64%) and their median age was 36 years (interquartile range [IQR]: 29, 46); sex was evenly distributed among the patients with COPD and their median age was 68 years (IQR: 61, 78). The majority reported having a family doctor (86% of the patients with asthma and 94% of the patients with COPD). On the day of admission to the ED, 29% of the patients with asthma visited their family doctor while 42% of the patients with COPD visited their Respirologist; these doctors referred >70% of the patients to the ED. While in the ED, consultations were requested in 21% of the patients with asthma (all to Pulmonary) and in 78% of the patients with COPD (evenly divided between Medicine and Pulmonary). Transition coordinators and social workers were involved in the ED care of <15% of the patients with COPD. Most patients with asthma were discharged home (86%) and 64% of the patients with COPD were hospitalized. After discharge, 14% of the patients with asthma and 50% of the patients with COPD were referred to specialized care. Conclusion: While the study patients with asthma and COPD had different health professionals providing regular care to their respiratory conditions, they both sought care before presenting to the ED. More health professionals were involved in the ED care of patients with COPD than of those with asthma. This study provided important information to support further research projects exploring ways to effectively and efficiently improve the delivery, comprehensiveness and utilization of health care services.
P155: Utilization of personal mobile devices to record patient data by emergency physicians and residents
Authors: Walker K. E. , Migneault D. , Lindsay H. C. , Abu-Laban R. B.
Published: May 2018

Introduction: The use of personal mobile devices to record patient data appears to be increasing, but remains poorly studied. We sought to determine the magnitude and purposes for which Canadian emergency physicians (EPs) and residents use their personal mobile devices (PMDs) to record patient data in the emergency department (ED). Methods: An anonymous survey was distributed to EPs and residents in the Canadian Association of Emergency Physicians (CAEP) database between 27/02/17 and 23/03/17. The survey captured demographic information and information on frequency and purpose of PMD use in the ED, whether consent was obtained, how the information was secured, and any possible implications for patient care. Participants were also asked about knowledge of, and any perceived restrictions from, current regulations regarding the use of PMDs healthcare settings. Results: The survey response rate was 23.1%. Of 415 respondents, 9 surveys were rejected for incomplete demographic data, resulting in 406 participants. A third (31.5%, 128/406, 95% CI 27.0-36.3) reported using PMDs to record patient data. Most (78.1%) reported doing so more than once a month and 7.0% reported doing so once every shift. 10.9% of participants indicated they did not obtain written or verbal consent. Reasons cited by participants for using PMDs to record patient data included a belief that doing so improves care provided by consultants (36.7%), expedites patient care (31.3%), and improves medical education (32.8%). 53.2% of participants were unaware of current regulations and 19.7% reported feeling restricted by them. Subgroup analysis suggested an increased frequency of PMD use to record patient data among younger physicians and physicians in rural settings. Conclusion: This is the first known Canadian study on the use of PMDs to record patient data in the ED. Our results suggest that this practice is common, and arises from a belief that doing so enhances patient care through better communication, efficiency, and education. Our findings also suggest current practices result in risk of both privacy and confidentiality breaches, and thus support arguments for both physician education and regulation reform.
P156: Exploring educational innovation: out of the shadows of shadow week
Authors: Wawrykow T. , Mawdsley H.
Published: May 2018

Introduction: In the third year of medical school, students participate in a four week period called Transition to Clerkship, followed by Shadow week, where students spend one week in the discipline prior to starting clerkship. In the past, students have identified that receiving specific additional training during Shadow week would help them succeed in their rotation. To address this problem, the curriculum discussed in this paper is being developed for third year students who will be commencing clerkship in Emergency Medicine (EM). Methods: In order to assess achievement of objectives within the curriculum, questionnaires were provided to participants in the morning and afternoon of the session, as well as at the end of their rotation. Evaluative analysis is done through the Kirkpatrick program evaluation framework based on descriptive comparison of scores on the questionnaires, followed by statistical analysis with the Mann-Whitney Test (2-tailed, p=0.05) and a reflective critique. Results: Learning activities in this curriculum included: case-based learning, video critique, role play, scavenger hunt, jigsaw activity, think-pair-share, and a game-show style game. This study aims to show if, and how, providing interactive, hands-on learning sessions, which are directly relevant to clinical practice in the emergency department, positively impacted medical students beginning their clerkship in EM. Conclusion: Learners showed statistically significant positive improvement on all learning objectives of the curriculum. A reflective critique provides insight into lessons learned from delivering this curriculum and future directions for this curriculum. This learner-centered curriculum with innovative teaching methods and a considerable number of active learning strategies has encouraged the learners to take responsibility for their own learning. While this curriculum took place in the medical school, it can apply equally to learners completing their EM clerkship in a community or tertiary Emergency Department.