bluuebunny/crossref_metadata_2025 huggingface dataset:
LO79: Patient-centred outcomes with use of CT angiography in patients presenting with acute stroke and TIA: a systematic review and meta-analysis
Authors: Li S.S. , Siarkowski M. , Trajkovski A. , Umakanthan A. , Kishibe T. , Lang E.
Published: May 2017

Introduction: It remains unclear whether widespread use of computed tomography angiography (CTA) in acute strokes and transient ischemic attacks (TIAs) has tangible benefits for patient outcomes or management. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) investigating the use of CTA and patient-important outcomes (recurrent stroke, mortality, disability, and emergency department (ED) revisits) or changes in management in patients presenting with acute stroke or TIA. PROSPERO: 349590 Methods: MEDLINE, EMBASE, and the Cochrane Registry were searched through May 24, 2016 for eligible trials. We included observational cohort studies and RCTs evaluating use of CTA against a control group for outcomes of interest in patients presenting acutely with suspected stroke or TIA. Two independent reviewers extracted data and assessed study quality using the Newcastle Ottawa Scale. Data for mortality and stroke rate were pooled by the generic inverse variance method and expressed as risk ratios (RRs) with 95% confidence intervals (95% CI). Data for disability were reported as the mean difference (MD) and 95% CI. Heterogeneity was assessed using the Cochran’s Q statistic and quantified by the I2 statistic. Overall strength of the evidence was assessed by the GRADE approach. Results: Three observational cohort studies involving 979 patients over an average of 1 year follow up met inclusion criteria; there were no eligible RCTs. CTA use in acute stroke or TIA patients was associated with a decreased mortality rate (RR=0.55, 95% CI 0.33 to 0.91, P=0.02; Phet=0.88, I2=0%). No changes were detected in stroke rate (RR=0.84, 95% CI 0.40 to 1.73, P=0.63; Phet=0.79, I2=0%). One study with data for disability showed no changes in mRS (MD=0.01, 95% CI -0.70 to 0.73, P=0.97). There were no eligible studies with data for ED revisits or changes in management. The strength of the evidence was assessed as very low quality due to imprecision for mortality, stroke rate, and disability. Conclusion: CTA use was associated with significantly reduced mortality in acute stroke and TIA patients, possibly due to confounding from poor baseline status of patients not receiving CTA. No significant changes were found for stroke rate or disability. There is a need for RCTs to confirm the effects of CTA use on patient outcomes and management.
LO80: Chest radiograph ordering for acute asthma presentations to emergency departments in Alberta: regional, site, and physician level variation
Authors: Krebs L. , Alexiu C. , Villa-Roel C. , Holroyd B.R. , Ospina M. , Pryce C. , Bakal J. , Jelinski S.E. , Rowe B.H.
Published: May 2017

Introduction: Most acute asthma presentations to the emergency department (ED) are uncomplicated and do not require chest radiographs (CXR). Evidence suggests that the proportion of acute asthma patients receiving CXRs in the ED is high and varies substantially within and across sites and studies. This study explored CXR ordering and variation in acute asthma presentations to Alberta’s EDs. Methods: Administrative health data for Alberta was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) acute asthma (ICD-10-CA: J45) ED visits from 2011-2015. Patients with a primary or secondary diagnosis of asthma were included, provided they had a Canadian Triage and Acuity Scale score of 2-5. NACRS data were linked with Alberta Health Services’ (AHS) diagnostic imaging database. Preliminary analysis on variation in imaging at the zone, ED site, and physician level was completed using SAS (v.9.4). Physicians who saw less than an average of 10 asthma patients per year were excluded. Results: Overall, 51,511 acute asthma ED presentations occurred (~10,000/year). The average proportion of CXRs among presentations was 39.5% (2011-2015) with an average annual increase of 6.7%. From 2011-2015, CXR ordering varied across the five AHS zones (variation [V]: 25%; range: 26.0%-51.0%). Substantial variation was observed across ED sites V: 60%; range: 5.9-66.4%) and physicians (V: 89%; range: 1.4-90.6%). The mean CXR ordering among physicians was 44%. Conclusion: From 2011-2015, CXR use among acute asthma ED presentations has increased. Substantial variation in CXR use suggests that evidence-based interventions are needed to improve imaging appropriateness.
LO84: Computed tomography use for headache presentations to emergency departments in Alberta: regional, site and physician level variation
Authors: Krebs L. , Alexiu C. , Villa-Roel C. , Kirkland S.W. , Gaudet L. , Holroyd B.R. , Ospina M. , Pryce C. , Bakal J. , Jelinski S.E. , Rowe B.H.
Published: May 2017

Introduction: Headaches are a common emergency department (ED) presentation. Evidence demonstrates that computed tomography (CT) imaging varies significantly within and across sites. This study explored CT ordering and variation among headache presentations across Alberta EDs. Methods: Administrative health data for Alberta were obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) headache (ICD-10-CA: G44, G43, R51) ED visits from 2011-2015. Patients with a primary or secondary diagnosis code of headache were included. Exclusions were: sites without CT scanners, Canadian Triage and Acuity Scale score of 1, patients with trauma or external mechanism of injury (e.g., ICD-10-CA S,T,V,W,X,Y), or enhanced/contrast CTs. NACRS data were linked with Alberta Health Services’ (AHS) diagnostic imaging data. Preliminary analysis on imaging variation at the zone, ED site, and physician level was completed using SAS (v.9.4). Physicians who saw less than an average of 10 headache patients per year were excluded. Results: Overall, 98,804 headache presentations were recorded (~20,000/year; 8.5% average annual increase) in 30 EDs. The average proportion of visits receiving CT was 25.1% with an average 6.2% increase per year. CT ordering varied across AHS zones (Variation [V]:23%; range:9.6-32.7%). Site ordering variation was more dramatic (V:45%; range:1.4-46.5%). The greatest variation was observed among physicians (V:84 %; range: 0.0-83.7%) with mean ordering proportion of 28.7%. Conclusion: From 2011-2015, headache presentations and CT imaging for these patients in the ED increased. Substantial variation in CT ordering exists at multiple levels in Alberta. Further exploration of CT appropriateness is urgently needed.
LO87: Use of a clinical prediction rule would lead to more effective CTA utilization for urgent brain imaging of suspected TIA/mild stroke in the emergency department
Authors: Votova K. , Bibok M. , Balshaw R. , Penn M. , Lesperance M.L. , Nealis M. , Farrell B. , Penn A.
Published: May 2017

Introduction: Canadian stroke best practice guidelines recommend patients suspected of Acute Cerebrovascular Syndrome (ACVS) receive urgent brain imaging, preferably CTA. Yet, high requisition rates for non-ACVS patients overburdens limited radiological resources. We hypothesize that our clinical prediction rule (CPR) previously developed for diagnosis of ACVS in the emergency department (ED), and which incorporates Canadian guidelines, could improve CTA utilization. Methods: Our data consists of records for 1978 ED-referred patients to our TIA clinic in Victoria, BC from 2015-2016. Clinic referral forms captured all data needed for the CPR. For patients who received CTA, orders were placed in the ED or at the TIA clinic upon arrival. We use McNemar’s test to compare the sensitivity (sens) and specificity (spec) of our CPR vs. the baseline CTA orders for identifying ACVS. Results: Our sample (49.5% male, 60.6% ACVS) has a mean age of 70.9±13.6 yrs. Clinicians ordered 1190 CTAs (baseline) for these patients (60%). Where CTA was ordered, 65% of patients (n=768) were diagnosed as ACVS. To evaluate our CPR, predicted probabilities of ACVS were computed using the ED referral data. Those patients with probabilities greater than the decision threshold and presenting with at least one focal neurological deficit clinically symptomatic of ACVS were flagged as would have received a CTA. Our CPR would have ordered 1208 CTAs (vs. 1190 baseline). Where CTA would have been ordered, 74% of patients (n=893) had an ACVS diagnosis. This is a significantly improved performance over baseline (sens 74.5% vs. 64.1%, p<0.001; spec 59.6% vs. 45.9%, p<0.001). Specifically, the CPR would have ordered an additional 18 CTAs over the 2-yr period, while simultaneously increasing the number of imaged-ACVS patients by 125 with imaging 107 fewer non-ACVS patients. Conclusion: Using ED physician referral data, our CPR demonstrates significantly higher sensitivity and specificity for CTA imaging of ACVS patients than baseline CTA utilization. Moreover, our CPR would assist ED physicians to apply and practice the Canadian stroke best practice guidelines. ED physician use of our CPR would increase the number of ACVS patients receiving CTA imaging before ED discharge (rather than later at TIA clinics), and ultimately reduce the burden of false-positives on radiological departments.
LO90: Trauma triage accuracy at a Canadian trauma centre
Authors: Pace J. , Tillmann B. , Ball I. , Leeper R. , Parry N. , Vogt K.
Published: May 2017

Introduction: Trauma teams have been shown to improve outcomes in severely injured patients. The criteria used to mobilize trauma teams is highly variable and debated. This study was undertaken to define the triage accuracy at our level 1 trauma centre and identify the criteria predictive of appropriate activations. Methods: A 3-month prospective observational study was performed and all patients presenting to the ER who received a trauma flag were identified. Patient demographics, vital signs, trauma team activation and criteria for activation were documented. Trauma activations were deemed appropriate if the patient met any of the following; airway intervention, needle/tube thoracostomy, resuscitative thoracotomy, ED blood product transfusion, invasive hemodynamic monitoring, central line insertion, emergent OR (<8 hours), admission to ICU, and death within 72 hours. Over and undertriage rates were calculated and a multivariate logistic regression was performed to identify activation criteria predictive of appropraite activations. The activation criteria were then modified and the prospective study was repeated to assess the impact on triage accuracy. Results: Between September to December 2015, 188 patients received a trauma flag. 137 patients met the activation criteria, however only 78 received a trauma team activation. 57% of patients who had TTA met the definition of appropriate activation, while 45% who met criteria for activation met the definition of appropriate. The rates of under and overtriage were 30.4% and 30.3%, respectively. Logistic regression revealed the following criteria to be predictive of appropriate activation; hypotension (OR 10.2 95% CI 2.3,45.5), arrival by HEMS (OR 3.2, 95% CI 1.4,7.6), pedestrian struck (OR 3.5, 95% CI 1.4,8.5) and fall (OR 5.1, 95% CI 1.7, 15.1). Tachycardia (OR 1.1, 95% 0.3,4.6) and high energy MVC (OR 1.4, 95% CI 0.7,3.1) were not found to be predictive. The post-modification study occured between September to December 2016. Data analysis to assess the impact of criteria alteration are currently underway and will be presented at CAEP 2017. Conclusion: Triage accuracy for the mobilization of a multi-disciplinary trauma team is important, both to ensure optimal patient care as well as to reduce unnecessary resource strain. Our previous criteria lead to high rates of undertriage and subsequent modifications have been made. The impact of these changes will be ascertained and presented at CAEP 2017.
LO96: Syncope prognosis based on emergency department diagnosis: a prospective cohort study
Authors: Toarta C. , Mukarram M.A. , Arcot K. , Kim S. , Gaudet S. , Sivilotti M. , Rowe B.H. , Thiruganasambandamoorthy V.
Published: May 2017

Introduction: Relatively little is known about outcomes after disposition among syncope patients assigned various diagnostic categories during emergency department (ED) evaluation. We sought to measure the 30-day serious outcomes among 4 diagnostic groups (vasovagal, orthostatic hypotension, cardiac, other/unknown) within 30 days of the index ED visit. Methods: We prospectively enrolled adult syncope patients at six EDs and excluded patients with pre-syncope, persistent mental status changes, intoxication, seizure, and major trauma. Patient characteristics, ED management, diagnostic impression (vasovagal, orthostatic, cardiac, or other/unknown) at the end of the ED visit and physicians’ confidence in assigning the etiology were collected. Serious outcomes at 30-days included: death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage. Results: 5,010 patients (mean age 53.4 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes: deaths (0.3%), arrhythmias (1.8%), non-arrhythmic cardiac (0.5%) and non-cardiac (0.9%). The cause of syncope was determined as vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of patients with ED investigations (p<0.001) and short-term serious outcomes increased (p<0.01) increased in each diagnostic category in the following order: vasovagal, orthostatic hypotension, other/unknown cause and cardiac. No deaths occurred in patients with vasovagal syncope. A higher proportion of all serious outcomes occurred among patients suspected of cardiac syncope in the ED (p<0.01). Confidence was highest among physicians for a vasovagal syncope diagnosis and lowest when the cause was other/unknown. Conclusion: Short-term serious outcomes strongly correlated with the etiology assigned in the ED visit. The physician’s clinical judgment should be incorporated in risk-stratification for prognostication and safe management of ED syncope patients.
GD04: A blinded, randomized controlled trial of opioid analgesics for the management of acute fracture pain in older adults discharged from the emergency department
Authors: Varner C. , McLeod S. , Orkin A. , Melady D. , Borgundvaag B.
Published: May 2017

Background: Emergency department (ED) providers are frequently challenged with how best to treat acute pain in older patients, specifically when non-opioid analgesics are ineffective or contraindicated. Studies have documented older patients presenting to the ED with painful conditions are less likely to receive pain medications than younger patients, and this oligoanalgesia has been associated with increased risk of delirium and longer hospital stays. Given the concerns for drug interactions, side effects, over-sedation and addiction, emergency physicians often report uncertainty regarding the ideal choice of opioid analgesic in older adults. There are no guidelines informing best practice for the management of acute pain in this population. Objective: The primary objective is to compare the efficacy of codeine, oxycodone and hydromorphone for acute fracture pain in older patients discharged from the ED. Methods: This will be a blinded, randomized controlled trial of older adults (age>70) discharged home from the ED with acute pain secondary to an upper extremity, lower extremity, rib, pelvic or vertebral compression fracture. Patients will be randomized to receive a 3-day supply of codeine, oxycodone or hydromorphone. Patients will also be given acetaminophen. Patients will be contacted by phone or email 3 days following their ED visit. The primary outcome will be differences in pain scores at 3 days assessed using the validated Brief Pain Inventory (Short Form). Secondary outcomes will include side effects (ie: confusion, constipation), adverse events (ie: falls, healthcare visits) and pain interference with daily activity. Patients, physicians and all research staff will be blinded to group allocation. Data Analysis Plan: The study design assumed three arms (codeine, oxycodone and hydromorphone), therefore the 2-tailed alpha will be set to 0.025 to adjust for the increased risk of type-I error with 3 pairwise comparisons. To test for pairwise equality between groups, a 1-way ANOVA will be employed. Proportional differences will be assessed using Pearson chi-square statistic. Sample size calculation: Assuming a mean (SD) change in pain scores between groups of 2.2 (3.0), a minimum clinically important difference on the Brief Pain Inventory of 2.0, a 2-tailed alpha of 0.025 to adjust for 3 pairwise comparisons and a beta of 0.20, we estimate that 47 patients per group (N=141) will be required. To account for potential loss to follow-up, we will increase our sample size by 25% per group, resulting in a final sample size of 177 patients (59 per group). Importance: All analgesics (including opioids) prescribed to older adults are associated with risk of adverse events. This study seeks to inform ED providers of opioid efficacy, side effects and patient-important, functional outcomes in this growing patient population.
GD05: Careful Anticoagulation Review in Emergency Medicine (CARe-EM)
Authors: de Wit K. , Mercuri M. , Worster A.
Published: May 2017

Background: The number of patients prescribed anticoagulation for stroke prevention is increasing, along with the proportion of emergency department (ED) patients who are anticoagulant users. Bleeding is the most common side effect. Inappropriate dosing, co-prescription of anti-inflammatories or aspirin, and renal impairment all increase the bleeding risk. An ED visit is an opportunity to review anticoagulant bleeding risks and intervene to prevent bleeding in patients at high risk. Objectives: To establish the 12-month incidence of bleeding in anticoagulated patients visiting the ED, to develop an ED specific anticoagulant-associated bleeding prediction score, to evaluate the ED utility of existing prediction scores. Methods: Research ethics board approval has been granted. Patients will be identified in Hamilton General and Juravinski EDs. Each patient will be followed forward in time for 12 months to document bleeding events. Population: Inclusion criteria: ED patients prescribed warfarin, rivaroxaban, dabigatran, apixaban, edoxaban or low molecular weight heparin (prevalent users). Exclusion criteria: Patients under 16 years of age. Primary outcome: The incidence of major bleeding (defined by ISTH criteria) within 12 months from the index ED visit. Secondary outcomes: Derivation of an ED prediction score to identify patients at high risk of anticoagulant-associated bleeding within 12 months. Tertiary outcomes: Evaluation of ATRIA, modified HAS-BLED and HEMORR2HAGES scores utility in predicting bleeding within 12 months. Data management: The data will be stored anonymously and securely on RedCAP. A literature search/expert discussion has identified multiple potential risk factors for bleeding. This data is collected at the time of the index ED presentation. A committee of emergency, thrombosis, gastroenterology and cardiology physicians will review each major bleeding case. Analysis: Primary analysis: a multiple logistic regression analysis to identify variables associated with major bleeding diagnosed within 12 months of the index presentation. Using the model β coefficients we will derive a simple clinical decision rule. Secondary analysis: assessing the area under the curve and optimal cut points for pre-existing bleeding prediction scores for predicting major bleeding within 12 months. Sample size calculation: With 3000 patients we expect 2700 to be anticoagulated long term, and at least 135/2700 patients will have a major bleed. This is a sufficient number for multivariate analysis to establish a simple model. We estimate 20,000 anticoagulated ED patient attendances/year. Importance: This is the first study to consider the ED visit an opportunity to prevent bleeding. We will establish a method to identify ED patients at high risk of anticoagulant-associated bleeding.
MP01: The canary in the coal mine: Does palliative care consultation influence emergency department utilization?
Authors: Polsky Z. , Lang E. , Sinnarajah A. , Fung T. , Thomas B.
Published: May 2017

Introduction: For cancer patients undergoing active treatment, emergency department (ED) visits may be an indicator of a breakdown in continuity and quality of care. Palliative care (PC) may be an important resource for patients in need of symptom management even during treatment with curative intent. This study aims to describe ED utilization by cancer patients and determine if PC consults impact ED use. Methods: Patient data from the Tom Baker Cancer Center (TBCC) was linked to PC and ED data as a retrospective cohort study. ED data was obtained from two administrative databases and PC data was obtained from four administrative databases and restricted to the first four hundred days following diagnosis. Univariate and Multivariate analyses were used. Results: Three actively treated cancer patient cohorts were identified based on first presentation following intake at the TBCC: 1) Used ED first (n=1637), 2) Used PC first (n=539), and 3) Only used services at the TBCC (n=2153). Using Multivariate analysis, patients living alone or who had a diagnosis of prostate or breast cancer were more likely to access the ED first or to only use services at the TBCC rather than access PC first. Patients who were divorced, on income support, or diagnosed with a lung or GI cancer, were more likely to access PC first rather than access the ED or only use services at the TBCC. A subgroup analysis was performed on those who accessed the ED at some point during their care, consisting of three groups: 1) ED Only Users (n=1091), 2) ED First Users, who also accessed PC (n=546), and 3) PC First Users, who also accessed the ED. There was a significant difference in rates of ED visits between the three groups: ED Only Users went to the ED at a rate of 3.8 per 1000 patient days; ED First Users, who also accessed PC, went to the ED at a rate of 7.7 per 1000 patient days; and PC First Users, who also accessed the ED, went to the ED at a rate of 9.2 per 1000 patient days (p< 0.001). Conclusion: In a tertiary cancer centre, patients who were divorced, on income support, or diagnosed with lung or GI cancer were more likely to access PC. Amongst those patients who presented to the ED, those who accessed PC first had higher rates of ED use. Further explorations of presenting complaints, utilization patterns, and symptom burdens will be analyzed to determine if early PC consults can influence or decrease ED utilization.
MP02: Paramedic safety culture across Eastern Ontario
Authors: Sinclair J.E. , Price P. , Austin M.A. , Reed A. , Kwok E.S.
Published: May 2017

Introduction: Safety culture is defined as the shared beliefs that an organization’s employees hold relative to workplace safety. Perceptions of workplace safety culture within paramedic services have been shown to be associated with patient and provider safety outcomes as well as safe work practices. We sought to characterize paramedics’ perceptions of the organizational safety culture across Eastern Ontario, Canada to provide important benchmarking data to evaluate future quality initiatives. Methods: This was a cross-sectional survey study conducted September 2015-January 2016 in 7 paramedic services across Eastern Ontario. We distributed an abridged version of Patterson’s previously published EMS-SAQ survey, measuring six domains of workplace safety culture, to 1,066 paramedics during continuing medical education sessions. The questions were presented for rating on a 5 point Likert scale (1=strongly agree, 5= strongly disagree) and a response of 1 or 2 was considered a ‘positive perception’ response. We present descriptive statistics and chi-square tests where appropriate. Results: We received responses from 1,041 paramedics (97.6%), with a response rate varying between 88.0% and 100% across the 8 paramedic services. One third (33.6%) were Advanced Care Paramedics (ACPs) and 39.4% of paramedics had more than 10 years’ experience. The percentage of positive responses for each domain were: Safety Climate 31.2% (95% CI 28.4-34.1), Teamwork Climate 29.3% (95% CI 26.6-32.1), Stress Recognition 56.8% (95% CI 53.8-59.8), Perceptions of Management 67.0% (95% CI 64.0-69.8), Working Conditions 42.6% (95% CI 39.6-45.7), Job Satisfaction 41.6% (95% CI 38.6-44.6). Primary care paramedics had more positive perception responses for Job Satisfaction (45% vs 35%, p=0.002), whereas ACPs had more positive perception responses for Stress Recognition (61.5% vs 54.1%, p=0.022). No association was found between gender or years of experience and a positive perception of any safety domain. Conclusion: The results provide valuable workplace safety culture data that will be used to target and evaluate needed quality improvement initiatives while also raising some awareness to paramedics of important factors related to patient and provider safety.
MP04: Interim analysis of the impact of the Emergency Department Transformation System on ambulance offload delay
Authors: Pawa S. , Van Aarsen K. , Dukelow A. , Lizotte D. , Zheng M.
Published: May 2017

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two London, Canada tertiary care Emergency Departments (ED) between April 2014 and July 2016 to improve patient care by increasing value and reducing waste. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards, and a novel initial assessment process. Offload delays are associated with longer hospital length of stay and delayed admission, and may increase morbidity and mortality. Delays also result in fewer circulating ambulances in the community. CIHI sets a benchmark of 30 minutes as an acceptable offload target. It is possible that EDST may have impacted offload times. Methods: Middlesex-London EMS provided offload times. Data was collected from London Health Sciences Centre including daily ED visit volumes, ED occupancy, offload nursing hours, and site variation. A binomial logistic regression analysis was performed to determine the impact of interventions and confounding variables on the proportion of patients meeting CIHI benchmark. A chi-square analysis was done comparing proportion of patients meeting the benchmark in the first 3 months versus the last 3 months to identify overall impact of EDST to date. Results: Increased offload nursing hours had a positive impact (p<0.001) on the proportion of offload times meeting the CIHI benchmark while increased ED visit volume and hospital inpatient volume had a significant negative impact (p<0.001). At both ED sites, the proportion of patients meeting the offload target ranged from 58-83% over the timeframe. There was a significant increase in the proportion of patients meeting the benchmark from the first quarter to the last quarter (69.6% vs 75.0%; 95% CI 3.45% to 7.38%, p=0.000). Specific interventions had varying degrees of impact on offload times. Conclusion: The proportion of patients meeting the benchmark offload time varied over the study timeframe but significantly increased with EDST implementation. Offload times are one of many outcomes we aim to improve with EDST and it remains an ongoing process as new interventions continue to be implemented. Once transformation is complete, future studies will focus on the impact of EDST on all ED flow metrics, and patient and provider satisfaction.
MP07: Office-based family physicians’ use of point of care ultrasound for early pregnancy complaints
Authors: Varner C. , McLeod S.L. , Hu S. , Bearss E. , Singwi A. , Lee S. , Borgundvaag B.
Published: May 2017

Introduction: In Canada, family physicians (FPs) provide the majority of early pregnancy care. To receive a same day US, most patients will be sent to the emergency department (ED). FPs are starting to use point of care ultrasound (POCUS) for a variety of indications. The FaMOUS course was modeled after the Canadian Emergency Ultrasound Society (CEUS) ED Echo (EDE) curriculum and adapted with permission for FPs. The objective of this study was to assess the indications for POCUS use in early pregnancy and determine the diagnostic accuracy of POCUS performed by FPs following FaMOUS certification to detect intrauterine pregnancy (IUP) and fetal cardiac activity (FCA). Methods: This was a prospective, observational study conducted in 3 FP clinics from November 2015 to June 2016. Pregnant women <20 weeks gestational age who underwent a focused, transabdominal POCUS by a FaMOUS-certified FP using a handheld GE VScan were enrolled. FPs documented the presence or absence of IUP and FCA. The reference standard was radiologist-interpreted US performed after the FP POCUS. FPs were surveyed to assess provider confidence using POCUS and perceived impact on clinical decision-making. Results: Of 253 eligible patients, 56 (22.1%) underwent POCUS. Of these, 50 (89.3%) had a radiologist-interpreted US following the office-based FP visit. POCUS was used for the following indications: 11 (19.6%) had vaginal bleeding, 5 (8.9%) had abdominal pain, 7 (12.5%) had both vaginal bleeding and abdominal pain, and the indication for 33 (58.9%) patients was unclear. All patients had a documented IUP, resulting in a sensitivity of 94.0% (95% CI: 83.5%, 98.5%) and 100% positive predictive value. FCA resulted in sensitivity of 82.9% (95% CI: 69.2, 92.4%) and specificity of 100% (95% CI: 29.2%, 100.0%). When surveyed, 100% of FPs were confident performing POCUS and reported POCUS had an overall positive impact on clinical practice. 75% agreed the use of POCUS decreased the need for urgent radiologist-interpreted US. Conclusion: Following a certification process modeled after the CEUS EDE curriculum, FPs used POCUS for both CEUS-defined indications and indications that were unclear. FPs trained in early pregnancy POCUS demonstrated excellent diagnostic accuracy identifying IUP and FCA. Future study should assess the clinical impact of office-based POCUS, including whether its use results in decreased ED visits for this patient population.
MP10: How dry I am: how much fluid do paramedics give when they administer an IV fluid bolus?
Authors: Eby D. , Woods J.
Published: May 2017

Introduction: How is “administer a fluid bolus” interpreted by paramedics? There is no existing literature describing this practice in the prehospital setting. Paramedic medical directives authorize the administration of Normal Saline 20 ml/kg to hypotensive patients (systolic BP <90). Anecdotally, auditors of Ambulance Call Reports (ACRs) and paramedics report this amount of fluid is rarely administered. The aim of this study was to determine the amount and rate of IV fluid administered by Advanced Care (ACP) and Primary Care (PCP) paramedics when they give an IV ‘fluid bolus’ during an ambulance call. Methods: We conducted a retrospective analysis of iMedic platform, electronic, ACRs (January 01, 2015 to June 30, 2015) from 8 municipal paramedic services that serve an urban and rural population of 1.4 million. ACRs containing a procedure code 351 (intravenous fluid bolus) were identified. A stratified, random sample of 20 cases per paramedic category (ACP and PCP) from each service was generated using a random number table. ACRs were manually searched, data abstracted onto spread sheets, and the results analyzed using descriptive statistics (Wizard ver 1.8.16 for Mac). Results: The initial sample was 220 cases. 25 were excluded for incomplete documentation, leaving 195 cases (ACP 59, PCP 136) for analysis. The mean IV fluid bolus volume delivered was: ACP 414.8 ml (95%CI: 344.2, 485.4), PCP 242.3 ml (95%CI: 210.9, 274.5). The mean rate of infusion was: ACP 22.7 ml/min (95%CI: 17.6, 27.8) PCP 15.7 ml/min (95%CI 13.2,18.1). Percentage of cases where >250 ml was infused: ACP 74.6%, PCP 44.1%. Percentage of cases where at least 10 ml/kg of fluid was given: ACP 17.0%, PCP 2.9%. Percentage of cases reaching the maximum 20 ml/kg of fluid: ACP 0.5%, PCP 0%. IV cannula size: 18G-ACP 57.4%, PCP 33.3%; 20G ACP 37.0%, PCP 56.8; 22G ACP 0.6%, PCP 9.8%. Conclusion: Paramedics rarely gave the amount of IV fluid they were authorized to give to hypotensive patients. On average, Advanced Care Paramedics administered significantly more fluid and gave it significantly faster than Primary Care Paramedics. ACPs were more likely than PCPs to use 18G cannulas and rarely used 22G cannulas whereas PCPs preferred to use 20G IV cannulas. Further training is required to clarify and improve the paramedic practice of IV bolus administration.
MP11: A quality improvement initiative to decrease the rate of solitary blood cultures in the emergency department
Authors: Choi J. , Ensafi S. , Chartier L.B. , Van Praet O.
Published: May 2017

Introduction: Best practice guidelines recommend that at least two sets of blood cultures be sent when blood cultures are required. However, high rates of solitary blood cultures are still common in the emergency department. The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the lab on patients ultimately discharged from our emergency department. Methods: This was a multi-centre, multi-phase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts. Results: The baseline rate of solitary sets of blood cultures was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a forcing function with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (P=0.071). However, the forcing function produced a statistically significant improvement (P < 0.0005), which was maintained for 6 months. Conclusion: The combination of a brief education-based intervention and a computerized forcing function was more effective than education alone in reducing solitary blood culture collection in our emergency department in this time series study. Forcing functions can be a powerful tool in modifying behaviours and processes in the clinical setting.
MP15: Profile and circumstances of cycling injuries: Data from an urban emergency department
Authors: Brubacher J.R. , Yip R. , Trajkovski A. , Lam C. , Sutton G. , Liu T. , Chan H.
Published: May 2017

Introduction: Cycling as a form of active transportation is popular in many urban communities. However, little is known about the prevalence and circumstances of cycling injuries, particularly injuries resulting from single bicycle crashes which are not recorded in road trauma surveillance systems based on police crash reports. This study aimed to examine the profile and circumstances of cycling injuries seen in an urban emergency department (ED). Methods: This was a cross-sectional historical chart review study. All injured patients attending our ED are electronically flagged according to mechanism of injury. We reviewed the medical charts of all ED visits in 2015 that were flagged as “Cyclist Injury” or “Fall” to identify all cyclists who were injured while travelling on public roads (including sidewalks). Off road injuries were excluded. Results: In 2015, a total of 6450 ED presentations were flagged as cyclist injury (n=694) or fall (n=5756), and 667 cycling injuries met our inclusion criteria. Of these, 73 (11%) were admitted to hospital. The most common mechanisms of injury were fall from bicycle (51%), crash into stationary object (16%), and collisions with moving motor vehicles (25%). Potential contributing factors included alcohol or drug impairment (11%), road hazards (9%), avoidance manoeuvre (5%) and dooring (3%), although the cause of the crash was generally poorly documented in the medical charts. The most common injured body regions were upper extremity (55%) followed by head and neck (34%). Most injuries were abrasions/lacerations and fractures. Conclusion: Two thirds of cyclist injuries in this series were caused by single bicycle incidents, events not captured in official road trauma statistics which are based on police crash reports. The large majority of injured cyclists were treated and released from the ED. In most cases, the cause of the crash was poorly documented. This data highlights the limitations of using police crash reports or hospital admission records for road trauma surveillance and the significant knowledge gap in our understanding of causative factors leading to cycling injuries.
MP17: Improving Communications during Aged Care Transitions (IMPACT): lessons learned
Authors: McLane P. , Tate K. , Rowe B.H. , Estabrooks C. , Cummings
Published: May 2017

Introduction: When patients transition from long term care (LTC) to emergency departments (ED), communication among clinicians in different settings is often poor. We pilot tested a transfer form to facilitate communications of handover information among LTCs, emergency medical services (EMS), and EDs regarding LTC residents transitioning to and from the ED. We interpret implementation challenges in light of the “theoretical domains” implementation framework in order to produce lessons for future healthcare communication interventions. Methods: We provided setting specific training and a user guide to 13 participating sites, collected 90 forms to assess completion rates, and assessed perspectives on the form from 266 surveys of healthcare providers. Throughout the study, staff kept detailed notes on implementation of the form. We retrospectively categorized implementation challenges reported by survey respondents, and/or recorded in staff implementation notes, according to the theoretical domains framework. Results: The LTC patient transfer forms were used in 36.4% of transitions (90/247), and were completed most often by staff in the LTC (57/90, 63%). Survey results indicated that ED and EMS staff felt the information on the form was useful to them, although they rarely completed their sections of the form. Implementation challenges included low awareness/recognition of the form among healthcare providers, belief that the form distracted from patient care, lack of time for form completion, negative reinforcement for LTC staff (who saw little return for the time they invested in completing the form), and mistrust among clinicians who work in different settings. Conclusion: Future efforts to improve healthcare communications must be acceptable for all clinicians. Innovation should balance the workload required among sites/clinicians and the benefits that the intervention offers to sites/clinicians should be explicitly tracked and reported. For this intervention, more effort should be made to inform LTC sites that the transfer information they provide is useful for EMS and ED clinicians. Moreover, gaps in perspectives and lack of trust among clinicians who work in different settings must be recognized and addressed in any multi-site communication intervention.
MP20: Prevalence of incidental findings on chest computed tomography in patients with suspected pulmonary embolism in the ED
Authors: Anjum O. , Ohle R. , Bleeker H. , Perry J.J.
Published: May 2017

Introduction: Computed tomographic pulmonary angiograms (CTPAs) are often ordered to evaluate pulmonary embolism (PE) in the emergency department (ED). However, these studies often yield alternative diagnoses and report incidental findings that lead to additional unnecessary investigations. Our objective was to assess the prevalence and significance of such findings and their implications in patient management. Methods: This is a retrospective cohort study of adults presenting to two tertiary care EDs in 2015, being evaluated with CTPA for PE. Data was extracted by two reviewers from electronic CT records with inter-rater reliability reported using kappa statistic. We measured prevalence of PE, incidental findings and alternative diagnoses with data reported as mean and standard deviation (SD). Univariate analyses were performed with t-test for continuous variables and Mantel-Haenszel test for categorical variables. A sample size of 770 was calculated based on an expected difference in prevalence between significant and non-significant incidental findings of 80% (α=5%, Power=90%). Results: A total of 1629 studies were included (mean 62 yrs, SD 16.7, 56.9% female, median CTAS score 2, 45.2% admitted). PE was found in 233 (14.3%) patients. 173 (10.6%) studies had a finding of an alternative diagnosis, the majority being pulmonary infiltrates (n=130, 75.1%). In patients who underwent both CTPA and chest x-ray (CXR), CXRs alone would have led to the same alternative diagnosis in 116 (77.1%) patients. A total of 223 (13.6%) patients had an incidental finding; the majority included pulmonary nodules (n=83, 37.2%) and adenopathy (n=26, 11.6%). Only 26 (17.1%) incidental findings were significant; most common included pulmonary nodules (n=6, 3.9%) and masses (n=7, 4.6%) that lead to newly identified and biopsied lung cancer diagnoses. Incidental findings led to an additional 301 follow-up CTs with a yield of significant result of 9.2% (n=48 CTs). Conclusion: Chest CTs ordered in the ED for clinical suspicion of PE is equally as likely to identify alternative diagnoses or incidental findings as PE. The majority of incidental findings are non-significant and result in an increased use of CT. CXRs should routinely be ordered prior to further investigation for PE with chest CT to reduce unnecessary testing and thus time and cost to the system.
MP22: The impact of collaborative social media promotion on the dissemination of CJEM articles
Authors: Huang S. , Milne K. , Martin L.J. , Bond C. , Mohindra R. , Yeh C. , Chin A. , Sanderson W.B. , Murray H. , Chan T.M. , Thoma B.
Published: May 2017

Introduction: The CJEM Social Media Team was created in 2014 to assist the journal with the dissemination of its research online. It consists of two Social Media Editors (Junior and Senior) and a team of volunteer medical students and residents to assist their work. Collaborative promotional agreements were developed to promote CJEM articles on the Skeptics’ Guide to Emergency Medicine (SGEM) podcast through the ‘Hot off the Press’ (HOP) series and the CanadiEM blog through an infographic series. Methods:
CJEM papers were selected for promotion by the Team based on their perceived interest to the online community of emergency physicians. Altmetric scores, which are a measure of online dissemination derived from a weighted algorithm of social media metrics, were collated for articles promoted using the SGEM HOP or CanadiEM blogs. A control group was created using the articles with the top two Altmetric scores in each CJEM issue in 2015 and 2016. Erratum, Letters, and articles written by the social media editors were excluded from the control groups. The success of the social media promotion was quantified through the measurement of Altmetric scores as of January 1, 2017. Unpaired two-tailed t-tests with unequal variance were used to test for significant differences. Results: 106 and 82 eligible articles were published in 2015 and 2016, respectively. Four articles in 2015 and two articles in 2016 were excluded from the control groups because they were written by the social media editors. SGEM HOP podcasts promoted one article in 2015 and five articles in 2016. CanadiEM infographics promoted three articles in 2015 and eight articles in 2016. No articles were promoted in both series. The average Altmetric score was higher for SGEM HOP (61.0) than CanadiEM Infographics (31.5, p<0.04), 2015 controls (15.8, p<0.01), and 2016 controls (13.6, p<0.01). The average Altmetric score for CanadiEM Infographics was higher than 2015 controls (p<0.04) and 2016 controls (p<0.02). There was no significant difference between the control groups. Conclusion: The results suggest that collaborating with established social media websites to promote CJEM articles using podcasts and infographics increases their social media dissemination. Given the nonrandomized design of these results, causative conclusions cannot be drawn. A randomized study of the impact of social media promotion on readership is underway.
MP26: Rate and outcome of incidental findings among abdominal computed tomography scans in the emergency department
Authors: Bleeker H. , Ohle R. , Anjum O. , Perry J.J.
Published: May 2017

Introduction: With the increased accessibility of computed tomography (CT), use in the emergency department has increased. Increased use has lead to a reduction in missed diagnoses but also an increase in radiation burden and the increased likelihood of incidental findings. In this study, we sought to characterize the use of abdominal CTs at an academic tertiary center in order to quantify the rate and clinical significance incidental findings. Methods: This was a retrospective chart review of radiological database of all abdominal CT ordered by the emergency department from January 1st to March 21st 2015. Incidental findings requiring follow up were defined by the American college of radiology guidelines. Clinically significant incidental findings were defined as those that resulted in a finding of malignancy or comparably serious disease. Abdominal CTs were excluded if they were ordered together with CT thorax. The data was abstracted by one trained reviewer using a standardized data collection sheet and 10% of the data was verified by a second reviewer. Inter-rater reliability reported by Kappa statistic. Data were reported as mean and standard deviation. A sample size of 770 was calculated based on an expected difference in prevalence between significant and non-significant incidental findings of 80% (α=5%, Power=90%). Results: A total of 1882 imaging studies were included (56.3% female, age 59.4 years (16.3), CTAS 3 (1.3). The most common presenting complaints: abdominal pain (980, 52.1%), flank pain (196, 10.4%) and nausea/vomiting (111, 6%). Indications included rule out (r/o) obstructing renal stones/colic (329; 17.5%), r/o diverticulitis/colitis (307; 16.4%) and abdominal pain not yet differentiated (283; 15.1%). The most common final diagnoses as a result of CT were renal stone/colic (212, 11.3%), colitis/diverticulitis (191, 10.2%), and bowel obstruction (111, 6%).Incidental findings recommending further imaging occurred in 93 (4.9%). Of these, 43 were completed, and 15 resulted in clinically significant findings: cancer of the colon (2), lung (2), bladder (2), metastatic cancer (2), adnexa (4), endometrium (1), lymphoma (1), and venous thrombus (1). Conclusion: Incidental findings are far less common (5%) then previously reported (as high as 30%) and rarely clinically significant.