bluuebunny/crossref_metadata_2025 huggingface dataset:
P040: Development of a categorization tool for delayed hemothoraces in patients with closed minor thoracic trauma
Authors: Eramian D.
Published: June 2016

Introduction: Thoracic trauma is, depending on severity, a frequent cause of mortality, morbidity, hospitalization and incapacity. Minor closed thoracic injuries are often discharged from Emergency Departments (ED) and treated on an outpatient basis. One potential complication is the development of a delayed hemothorax (DHx). Currently, there exists no consensus on the best method for classifying DHx. The goal of this study is to evaluate the level of interrater and intrarater agreement with respect to three classification schemes for DHx. Methods: This was a secondary analysis drawn from a prospective multicenter cohort study of consecutive patients presenting to one of four Canadian ED for minor closed thoracic trauma over a four-year period. Using intraclass correlation (ICC), chest radiographs of 50 patients previously diagnosed with new DHx within 2 weeks of discharge were randomly selected and subjected to analysis by emergency physicians, radiologists, surgeons and family physicians using three different methods of classification to study their reliability, both between raters and for the same rater on two separate evaluations, at determining hemothorax severity. Results: Analysis of ICC values demonstrates poor interrater agreement (Global ICC 0.44, 0.35-0.52) for the current classification method, based on professional experience and opinion. The second method, based on hemothorax / total thorax ratio calculation, showed good Global ICC (0.58, 0.49-0.67) on lateral films. The third method, based on presence / absence of overflow from the costo-phrenic angle, showed equally good Global ICC (0.56, 0.47-0.64) on postero-anterior films and was more homogenous across the four different groups of physicians. Conclusion: Our results demonstrate that the current method used to classify DHx, based on gestalt, shows poor interrater agreement. Two innovative classification methods achieved good interrater agreement. Future studies, analyzing possible correlation of this more reliable classification method to objective, clinical measures would be of value to management decisions.
P042: Use of technology to create economically sustainable supplemented triage: a feasibility study at an urban tertiary care centre
Authors: Filipowska C.H. , Mazurik L.
Published: June 2016

Introduction: Decreasing patient Length of Stay (LOS) in the Emergency Department (ED) improves patient safety. Numerous studies have taken differing approaches to supplementing care at triage in order to decrease LOS, however, have not proven to be financially sustainable. The goal of this study was to explore financially viable options to expedite care in a safe way and reduce patient LOS. Methods: The ED process chain was identified. Two reviewers observed triage for a 4-hour period following patients. Times from patient arrival to: completion of triage, completion of registration, test ordering, physician assessment and final disposition were measured. Results were presented at departmental rounds. Nursing staff, Physician Assistants, Residents and Physician staff were paired in interdisciplinary groups to brainstorm and trial approaches to expedited test ordering and use of technology to carry out orders. Results: Triage interruptions increased time to triage a patient up to 3 times baseline, and 33% of triage interactions were interrupted. A bottleneck occurred at registration, increasing time to be registered by up to 30 minutes. Also, registration is using antiquated technology, significantly increasing registration time. Average patient LOS was 249 min, but was only 120 min if there was no delay in test ordering for patients. Average time for MD disposition was 129 min, but was only 47 minutes if there was no delay in ordering tests. Brainstorming lead to the following ideas: 1) use of companion phones to access already-working ED MD for test ordering and ECG interpretation 2) the use of the computer system to flag new orders or ECG for triage patients 3) use of a dedicated iPad in zones 4) increased standing orders for RNs to order diagnostic imaging. Conclusion: Patient LOS was reduced by lack of delay in test ordering, in keeping with previous studies. Numerous points in the process chain were identified for creating an economically sustainable supplemented triage to improve patient flow. These were: interruptions to triage, registration bottleneck, technology at registration, test ordering at triage. Ways in which to effectively order tests at triage include: MD-companion phones, pre-existing computer program, dedicated iPad in zones. The next step in this study is to trial each of these low-cost technologies.
P044: HEADSTRONG: helmet education, advocacy, distribution & social media trial to reduce obstacles & nudge group behaviour
Authors: Friedman S.M. , Kuipers M. , Ackery A.
Published: June 2016

Introduction: Head injury is a major cause of bicycling-related disability and death, and more likely to occur in unhelmeted riders. Legislation regarding helmet use varies by province. In Ontario, helmet use is not mandatory for cyclists >= age 18, and approximately 50 % of adult cyclists do not routinely wear helmets. Non-legislative approaches to increase helmet use have included education, public health campaigns, and helmet giveaways, but sustained effect is typically limited. The goal of the HEADSTRONG Behaviour Study is to identify injured adult cyclists who do not regularly wear helmets, and effect sustained helmet use. The strategy incorporates evidence-based elements of health behaviour change, including: reducing barriers, education and modelling, providing necessary materials, and social support. Methods: Prospective cohort study in downtown Toronto teaching hospital, launched Nov 2015. ED clinician (EP or NP) will recruit injured cyclists (consecutive, convenience sample) who report not regularly wearing a helmet nor owning a suitable one. Study endpoint: 100 enrolled (to estimate prevalence of usage of +/- 10%, alpha 0.05, power >90%, assuming 80% study completion and 50 % helmet wearing at 12 months). Exclusion criteria: unable to consent, admitted to hospital, age <18. Each element of the HEADSTRONG Behaviour Strategy is intended to facilitate patient adoption and maintenance of the desired behaviour, including: 1) enrolment/education by research associate while still in the ED; 2) provision and fitting of a free bicycle helmet; 3) social contract commitment and tailored reminders to document ongoing helmet use: participant agrees to respond to brief electronic survey follow-ups at two weeks, two months, six months, and twelve months; 4) social media engagement with participation in the HEADSTRONG Twitter group, which engages other enrolees and cycling advocacy groups; 5) peer nomination: the participant who is complying with the social contract is encouraged to nominate an uninjured non helmet-wearing colleague to enrol in the study. Results: Primary outcomes include: recruitment rate, enrolment, and sustained participation through follow-up period. Secondary outcomes include age, gender and social demographics of helmet recipients, and participation of peers. Conclusion: Discussion of strategy and interim results at six month interval will be presented at CAEP.
P059: “Rate and See” – a pilot evaluation of a short duration atrial fibrillation pathway linking the emergency department to specialty care
Authors: Kwan A. , Halperin F. , Gorman N. , Janicki L. , Halperin L. , Harris D.R.
Published: June 2016

Introduction: Rapid atrial fibrillation (AF) and flutter remains a common cause of emergency department (ED) visits. Canadian guidelines recommend a rhythm control strategy for patients presenting to ED within 48 hours of arrhythmia onset or who are anticoagulated. However, up to 70% of patients spontaneously convert within 24 hours, mitigating the need for urgent cardioversion. Moreover, education, risk stratification, appropriate anticoagulation, and follow-up may be challenging in the ED setting. Therefore, direct and rapid linkage to an AF clinic was proposed to address these gaps in care. Methods: A pilot evaluation of a “Short Duration AF Pathway” was performed at Kelowna General Hospital, B.C., from June 2014 to Feb 2015. This care pathway–consisting of a treatment algorithm, ED order set, and referral process–was applied to patients with AF≤48 hours or those who were anticoagulated. Patients received initial rate control medication in the ED and were referred for reassessment in a collaborative cardiologist/nurse practitioner AF clinic and seen within 24 hours. Data was collected prospectively; descriptive statistics are presented. Results: Twenty patients were enrolled during the pilot period. Mean age was 69 (SD=10) years, 6/20 (30%) female, mean CHADS65 score 1.35 (SD=1.1), with 15/20 (75%) CHADS65 ≥ 1. On presentation, 4/20 (20%) were taking anticoagulants and 12/20 (60%) had an AF history. All 20 patients were assessed in the AF clinic within 24 hours of referral. Upon assessment in the AF clinic, 10/20 (50%) had spontaneously converted to sinus rhythm and 5/20 (25%) were electrically cardioverted at the first AF clinic visit. The remaining 5/20 (25%) of patients were reclassified as AF of uncertain duration; one was admitted to hospital, the other four had delayed electrical cardioversion. All patients received education related to AF. No adverse events or readmissions to the ED were reported and 100% of patients with CHADS 65≥1 had received appropriate anticoagulation. Conclusion: A “Short Duration AF Pathway” is a viable alternate approach to immediate cardioversion within the ED. Potential advantages include avoiding unnecessary cardioversion, providing patient education, accessing timely specialty care, and initiating anticoagulation where appropriate.
P061: Mobile digital access to a web-enhanced network (mDAWN): mHealth for type-2 diabetes self-management and implications for emergency medicine
Authors: Ho K. , Novak Lauscher H. , Newton L. , Boothe A.
Published: June 2016

Introduction: Diabetes mellitus affects over 2.7 million Canadians, with 90% being Type-2 diabetes (CDA 2010). Complications of diabetes are major causes for emergency department (ED) visits, adversely affecting patients’ health and costing the health system. Improving diabetes self-management can lead to avoidance of ED visits and revisits after discharge. Recent developments in mobile Health (mHealth), such as home health monitoring with sensors, social media, and text messaging, have shown promise in supporting patients in chronic disease self-management. This project tested the feasibility of these tools to support self-management for people with type-2 diabetes. Methods: Forty-three people with type-2 diabetes took part in a three month program that provided: health information via text messages, online access to curated resources and a facilitated discussion board, and access to wireless monitoring devices. Participants were outfitted with a wireless blood pressure monitor and weight scale, standard blood glucose monitor, and online access to their physiological data. Data collected included pre and post-self-reported health measures, tracking of physiological changes, website and discussion board use, cost survey, and interviews. Results: Participants reported significantly less health distress and an increase in diabetes empowerment. HbA1c levels decreased from an average of 7.41 to 6.77. Average weight and blood glucose also decreased over the study period. Interview and cost survey findings revealed most participants felt mDAWN provided good value; 78% expressed interest in continuing all or parts of the program. Interview findings revealed that participants developed self-management routines, and experienced increased self-awareness of, and ownership over, their health achievements. Conclusion: mHealth tools provided participants with their own physiologic information, connection with peers, and evidence informed advice. Participants highly valued this combination and improved their self-management and health outcomes. Equipping patients with similar tools for self-management post ED discharge holds great promise for decreasing revisits and improving health outcomes. This study has stimulated a clinical trial now underway to evaluate the effectiveness of home monitoring to facilitate the transition of patients between acute care and community settings.
P062: Impact of pharmacist-led medication review in the emergency department on downstream health services utilization
Authors: Hohl C.M. , Wickham M.E. , McGrail K. , Sobolev B.G.
Published: June 2016

Introduction: Adverse drug events are a leading cause of Emergency Department (ED) visits and unplanned admissions. Up to 50% are misdiagnosed in the ED and on hospital wards leading to treatment delays. Our main objective was to evaluate the effect of pharmacist-led medication review in high-risk ED patients on the number of days in-hospital. Our hypothesis was that early pharmacist-led medication review may reduce the number of days spent in-hospital. Methods: We evaluated a quality improvement program that was implemented in three British Columbian EDs. During a 12-month period, nurses identified consecutive patients at high-risk for adverse drug events using a clinical decision rule integrated into triage algorithms. Clinical pharmacist research assistants enrolled consecutive eligible high-risk patients, and systematically allocated them to medication review or control. In the intervention group, pharmacists collected best possible medication histories, reviewed medications for appropriateness and adverse drug events, and communicated review results to patients and physicians. In the control group, nurses collected best-possible medication histories, and physicians referred patients to the ED pharmacist as needed. Ongoing care was determined by physicians who were not blinded to group allocation, but were unaware of the evaluation. We assessed outcomes using administrative health databases. The primary outcome was the number of days spent in-hospital over 30 days. We used inverse propensity score weighted regression modeling to assess the relationship between medication review and health outcomes. The sample size was limited by the duration of the quality improvement program. Results: Among 10,807 patients 6,416 received medication review in the ED and 4,391 usual care. The groups were balanced in terms of baseline characteristics. The median number of hospital days was 0.48 days (95% confidence interval [CI] 0.00-0.96) less in the medication review group compared to usual care (p=0.058). The difference was 0.60 days (95% CI 0.06-1.17; p=0.03) less among patients under 80 years old. There was no effect on ED revisits, number of admissions and readmissions, or mortality. Conclusion: Medication review was associated with a trend in reduced hospital-bed utilization. While limited by lack of randomization, our evaluation suggests that ED pharmacists may impact subsequent resource utilization.
P065: Surveying ED transition of care: satisfaction, awareness of risks and barriers to the implementation of a standardized protocol
Authors: Iseppon M. , Chauny J. , Cournoyer A. , Montplaisir I. , Daoust R. , Robert M.
Published: June 2016

Introduction: Patient handoffs have been identified as the primary cause of error affecting patient safety. The lack of standardization - and the often-avoidable errors that occur as a result - profoundly affect patient care and emergency department (ED) administration. Our study set out to evaluate emergency doctors’ awareness of these safety concerns, as well as their satisfaction with handoff practices currently used in their respective EDs. We also aimed to identify the potential barriers to the use of a standardized approach to patient transition of care. Methods: Guided by a modified Delphi method, a 29-question survey was developed by a panel of experts on patient transition of care. A printed version of the survey was distributed to ED doctors attending a local emergency medicine conference. An electronic version was subsequently distributed to all ED doctors registered as members of our provincial professional organizations. Results: We achieved a 68% response rate. Amongst the 309 participants, 51% (95%CI 44-56%) acknowledged that handoffs between emergency doctors are a frequent cause of error related to patient care. Frequent interruptions (77% (95%CI 72-82%)) and heavy workloads (73% (95%CI 68-79%)) were identified as the main factors negatively influencing the quality of handoffs. Despite 61% (95%CI 56-68%) satisfaction with the currently employed methods, 74% (95%CI 68-79%) of the respondents believe that handoffs would benefit from standardization and 83% (95%CI 79-88%) are open to changing their current practices. In addition, 53% (95%CI 48-60%) believe that the tools used for transition of care can be improved. Apprehension regarding the increase of handoff burden (86% (95%CI 81-90%)) was identified as the primary barrier to the implementation of a standardized handoff protocol. Conclusion: Doctors are generally satisfied with current handoff practices used in the ED. Nevertheless, their awareness of the possible risks associated with transition of care may be driving their openness to adapting their practice, potentially towards a more standardized approach given the conceivable benefits to patient safety. In light of these results, we aim to develop a comprehensive, standardized handoff protocol, and to evaluate its applicability in the ED with a prospective study.
P066: Comfort of emergency medicine physicians in implementing early goal directed therapy for sepsis
Authors: Kaicker J. , Pardhan A. , Upadhye S. , Healey A. , Chan T.M.
Published: June 2016

Introduction: The recently published ProMISe, ARISE and ProCESS trials demonstrated that protocol-based resuscitation (EGDT) of ER patients in whom septic shock was diagnosed did not improve outcome when compared to usual care. The objective of this project was to survey McMaster emergency physicians in areas including sepsis definition, clinical recognition in adults, self-rated skills assessment, attitudes towards skills augmentation and compare results to the cohort surveyed 11 years ago, close to the introduction of EGDT. Methods: Full time faculty at McMaster’s Department of Emergency Medicine and ER residents were surveyed anonymously using an electronic survey. The questions covered demographics and training data, identification of septic patients, sepsis intervention and attitudes towards skills augmentation. Results: A total of 18 physicians responded to the electronic survey to date. All respondents were able to correctly input definitions for SIRS, sepsis, severe sepsis and septic shock. The majority of respondents felt the best strategy to identify potentially septic adults involved monitoring abnormal vital signs (67%) with some stating serum lactate assessment (33%). Of the 11 possible interventions options provided to care for septic patients, respondents appeared more comfortable with placement of lines, giving vasopressors and appropriate use of fluids for resuscitation. This was compared to more specialized interventions like initiating IV steroids in vasopressor dependant shock despite adequate fluid loading. 22% of respondents believed that patients without respiratory compromise with clinically severe sepsis should be intubated which was found to be 48% in the previous cohort surveyed 11 years ago. 78% believed patients in septic shock without respiratory comprise should be intubated, reassuringly similar to the previous survey result of 87%. Conclusion: Emergency physicians at our Canadian institution are comfortable with the skill set required to care for patients with sepsis. Respondents surveyed to date were all comfortable with important resuscitative measures including accurate identification, placement of lines and appropriate fluid administration and were receptive to additional training. Our study emphasizes that our physicians have the skill set to identify and provide care for sepsis using their clinical judgment in cases that may not require protocolized based care.
P068: Developing a standardized knowledge dissemination tool for communicating the need for Choosing Wisely© in Alberta’s emergency departments
Authors: Krebs L. , Villa-Roel C. , Ospina M. , Holroyd B.R. , Rowe B.H.
Published: June 2016

Introduction: Standardized tools for disseminating knowledge summaries of low value or unnecessary care (e.g., testing, procedures and treatments) are limited, but needed to equip clinicians for discussions with patients about care decisions. The objective of this study is to assess the acceptability of a tool developed by our emergency department (ED) team to communicate the evidence supporting the Choosing Wisely Canada© (CWC) and other similar recommendations. Methods: A consensus process was used by team members to develop a tool that highlights three areas: Facts, Gaps, and Acts. The Facts portion highlights the current state of knowledge and illustrates the strength of the evidence supporting guideline recommendations. The Gaps section identifies variation in current clinical practice. The Acts section includes larger CWC goals, as well as specific next steps for a demonstration project. Each section contains one key message for clinicians, ensuring the tool is easy to use. Results: A test case has been developed for avoiding chest radiographs in patients with an exacerbation of documented asthma. The Facts section reviewed current guidelines for asthma care. The Gaps section collated evidence from a systematic review and primary research. The Acts section recapitulates the CWC recommendations. In order to assess acceptability feedback cycle will be completed using surveys of 50 patients and 50 clinicians. Conclusion: While generating the Facts, Gaps, and Acts tool for a CWC recommendation represents a translational activity, evidence of effectiveness is needed prior to widespread implementation. We report the rational and development of a novel tool to engage clinicians and patients in conversations about unnecessary care in the ED.
P070: Improving handovers in the emergency department: implementation of a standardized team approach
Authors: Kwok E.S. , White S.
Published: June 2016

Introduction: Handovers in the ED are a high risk area for breakdown in team communication, discontinuity of patients’ clinical course, and potential medical errors. This is especially true for morning handovers at our center, when one single overnight MD working with limited resources hands over the entire ED to an oncoming day team of MDs and allied health professionals. We describe a quality improvement (QI) project to implement an inter-professional team approach during handovers. Methods: This prospective QI project took place at an academic tertiary care centre with >160,000 ED visits/yr. An expert working group identified key components of the ideal morning handover, and developed an intervention consisting of standardizing the “location”, “participants”, and “time” components of our handover processes. A research assistant directly observed all 8am handovers for 2 weeks pre- and 2 weeks post-intervention. Outcomes include participant attendance; # of beside RN issues proactively brought forward; frequency of new allied health consults and/or involvement triggered; # of physician interruptions; and time metrics. We report descriptive statistics. Results: During the study period a total of 308 individual patient handovers were observed [Pre:162, Post:146]. Average duration of total handover each morning decreased from 24.9min to 16.3min (p=0.051). Frequency of attendance at handovers increased for various allied health professionals, including care facilitators [Pre:35.7%; Post:91.7%, p=0.005], social workers [Pre:7.1%; Post:66.7%, p=0.003], geriatrics EM (GEM) RNs [Pre:64.3%; Post:83.3%, p=0.391], pharmacists [Pre:0.0%; Post:58.3%, p=0.001], and physiotherapists [Pre:0.0%; Post:58.3%, p=0.001]. Number of specific beside RN issues proactively brought forward increased [Pre:0; Post:4, p=0.049], while the number of physician interruptions during handover decreased [Pre:20; Post:0, p<0.0001]. Frequency of new allied health consults and/or involvement triggered as a result of handover participation increased from 6.8% to 13.7% (p=0.057). Conclusion: Implementation of a standardized team approach to morning handovers in the ED led to significant improvements in inter-professional contributions to patient care plans and overall efficiency. Future planned phases will build on this QI initiative by standardizing specific content of ED handovers.
P071: Emergency physician attitudes and perceived barriers to take-home naloxone programs in Canadian emergency departments
Authors: Lacroix L. , Stiell I.G. , Thurgur L. , Orkin A.
Published: June 2016

Introduction: Unintentional overdose is the leading cause of injurious death among Americans aged 25-64 years. A similar epidemic is underway in Canada. Community-based opioid overdose education and naloxone distribution (OOEND) programs distribute take-home naloxone kits to people at risk of overdose in several cities across Canada. Due to the high rate of drug-related visits, recurrent opioid prescribing, and routine encounters with opioid overdose, Emergency Departments (ED) may represent an under-utilized setting to deliver naloxone to people at risk of opioid overdose or likely to witness overdose. The goal of this study was to identify Canadian emergency physician attitudes and perceived barriers to the implementation of take-home naloxone programs. Methods: This was an anonymous web-based survey of physician and trainee members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals, per the modified Dillman method. Respondent demographics were collected and Likert scales used to assess attitudes and barriers to the prescription of naloxone from the ED. Results: A total of 347/1658 CAEP members responded (20.9%). Of the respondents, 62.1% were male and residents made up 15.6%. The majority (48.2%) worked in Ontario and 55.7% worked in an urban tertiary centre. Overall attitudes to OOEND were strongly positive: 86.6% of respondents identified a willingness to prescribe naloxone from the ED. Perceived barriers included allied health support for patient education (56.4%), access to follow-up (40.3%), and inadequate time in the clinical encounter (37.7%). In addition to people at risk of overdose, 78% of respondents identified that friends and family members may benefit from OOEND programs. Conclusion: Canadian emergency physicians are willing to prescribe take-home naloxone to at-risk patients, but better systems and tools are required to facilitate opioid overdose education and naloxone distribution implementation. This data will inform the development of these programs, with emphasis on allied health support, training and education.
P072: Using the Bergman-Paris Question to detect ED seniors’ cognitive impairment and functional status
Authors: Laguë A. , Émond M. , Boucher V. , Daoust R. , Pelletier M. , Gouin E. , Berthelot S. , Voyer P.
Published: June 2016

Introduction: Mild Cognitive Impairment (MCI) remains frequently undiagnosed and Emergency Department (ED) guidelines suggest screening for CI. The Bergman-Paris Question (BPQ) which is currently used in memory clinics, is a one-question screening test administered to the patient’s relative; a negative answer suggests presence of CI. We sought to validate if the BPQ would be associated with MCI and functional status in ED elders. Methods: A planned sub-study of the prospective MIDI-INDEED study on ED-induced delirium, which included patients from 4 Canadian EDs was realized. Inclusion criteria were: patients ≥65 y.o., with and ED stay ≥8 hours, admitted to the hospital, non-delirious at the end of the first 8 hours and independent or semi-independent. Eligible patients were assessed in ED and at 60 days after ED visit using validated screening tests: the Telephone Interview for Cognitive Status-modified (TICS-m) for CI and the Older Americans Resources and Services scale (OARS) for functional status. The BPQ was asked at any time depending on the availability of a relative. Patients with a TICS-m score <31 are considered to have MCI. Data from patients with incident delirium, and those with documented dementia was individually analyzed. Univariate and multivariate analyses were used to ascertain outcomes. Results: 167 patients had a BPQ response, 126 (75.5%) were negative, and 41 positive (24.5%). For MCI, 40 (32.8%) patients of the negative group have a TICS-m below 31 comparatively to 6 (14.3%) for the positive group (p=0.2). The BPQ was significantly associated with functional status. The mean OARS scores were 25.1 (3.9) in the negative group and 27.1 (1.3) in the positive group. This difference was maintained at 60 days. The number of delirium in the negative group was 24 (18%) vs 2 (5%) in the positive group (p=0.04). Conclusion: BPQ could provide detection of MCI but further validation in a larger population is needed. BPQ was interestingly associated with ED-induced delirium and dementia. Detection of functional status and frailty shows good results. More research is needed to evaluate the usefulness of the BPQ “single” question for geriatric screening by ED professionals.
P075: Impact of pit-crew CPR following out-of-hospital cardiac arrest in Saskatoon
Authors: Netherton S. , Leach A. , Hillier T. , Woods R.
Published: June 2016

Introduction: Between 1980 and 2008, survival rates following an out-of-hospital cardiac arrest (OHCA) have remained unchanged, averaging 7.6%. Despite the use of new and emerging technologies, new medications, and automated external defibrillators, survival remains low. Recently, a new focus in cardiopulmonary resuscitation (CPR) has shown dramatic improvements in survival post OHCA. This new model, called pit-crew CPR, focuses on minimizing interruptions in chest compressions and has each team member playing a specific role in the resuscitation, akin to the pit-crew of a car race. Certain districts in the United States and Canada have adopted the pit-crew, or a similar, high quality, maximum time-on-chest CPR model, with much success. We aim to determine whether the pit-crew model of CPR improves survival following OHCA in Saskatoon, SK. Methods: In Saskatoon, EMS and Fire crews respond to OHCAs and have been exclusively using the pit-crew model of CPR since Jan 1st, 2015. This study is a before and after retrospective chart analysis, comparing two groups - pre and post implementation of the pit-crew CPR model. The primary outcome is survival to hospital discharge post OHCA. Secondary outcomes include survival to admission and any return of spontaneous circulation (as per the Utstein definition). The inclusion criteria are patients >18 years old with a witnessed OHCA of presumed cardiac origin who receive CPR by EMS/Fire within the Saskatoon Ambulance service (MD Ambulance) catchment area. Patients were excluded if the OHCA was unwitnessed, or if there was a presumed non-cardiac cause for the arrest, e.g. trauma. Results: In the pre-pit-crew model cohort, between Jan 1st, 2011 and Sept 31st, 2014, 455 OHCAs were analyzed. In this cohort 10.5% survived to discharge, 31.9% survived to admission and ROSC was achieved in 39% of cases. The percentage of patients with initial rhythms of VF/VT, asystole or PEA were 28.5% (26%), 41.5% (1%) and 23.6% (10%) respectively, with survival to discharge shown in parentheses. The post-pit-crew cohort is still in the data collection phase. Conclusion: Our pre-pit crew cohort data has been collected and analyzed. With ongoing data acquisition for the post-pit crew cohort, we hope to have the full data set complete by the end of 2018. It will be at that time when we are able to determine whether the pit-crew model of CPR improves survival to discharge following OHCA in Saskatoon.
P080: Factors predicting morbidity and mortality associated with pre-hospital “lift assist” calls
Authors: Leggatt L. , Davis M. , Columbus M. , Van Aarsen K. , Lewell M. , Dukelow A.
Published: June 2016

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. What places patients at an increased risk for morbidity and mortality is not yet known. Objective: To determine factors that are associated with increased risk of 14 day morbidity, determined by an ED visit or hospital admission, and mortality in LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). These calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days. Logistic regression analyses were run to predict ED visit or hospital admission within 14 days of the LA call from patients’ age, gender, co-morbidities and vital signs at the initial LA call. Results: Of 42,055 EMS calls, 808 (1.9%) were LA calls. There were 169 (20.9%) ED visits, 93 (11.5%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA. Patient age > 61 (p < 0.001) and history of cardiac disease (p = 0.006) significantly predicted ED visit, while patient age >61 (p = 0.001) and an Ambulance Call Record (ACR) missing at least 1 vital sign (p = 0.017) significantly predicted hospital admission. There was a 10% increase in risk of ED visit and hospital admission for every 10 year increase of age after the age of 61. Of the 96 patients with at least 1 missing vital sign, 14 (14.5%) were coded as patient refusals. The sample size was too small to determine predictors for mortality. Conclusion: Patients at risk for morbidity are older than 61 years of age and have co-existing cardiac disease. Patients who are greater than 61 years of age and had at least one missing vital sign on the ACR were more at risk for hospital admission.
P085: A low-cost solution to high-risk problem: enhancing communication of emergency physician x-ray interpretations to reading radiologist
Authors: MacKinnon D.J. , McGowan M. , Dowdell T. , Bandiera G.
Published: June 2016

Introduction: There was a recognized lack of available system for Emergency Physicians (EPs) to communicate their x-ray interpretations to the reading Radiologist; this resulted in unnecessary flagging of cases with significant findings already seen by the EP or the possibility of incorrectly assuming a finding was seen by the EP. Our aim was to develop an IT-based system that permitted Radiologists to view EPs documented x-ray interpretations real-time. Based on engagement with both groups, it was essential that the system be user friendly and not add significantly to an already busy workload. Methods: An online reporting system was introduced in 2011, but with complaints that interpretations were not readily accessible, nor automatic. A revised system was launched in 2014 with 2 improvements: i) EP entered interpretation onto “sticky note” in PACs directly; and ii) EP interpretation “popped up” when a film was opened by Radiologist. Results: Both systems allowed data collection of the percentage of events EPs entered an interpretation. Prior to 2011, 0% of films had EP interpretations available to Radiologist, 33% with initial, and 53% with PACS. The revised system has enabled EPs to enter their x-ray interpretation which has resulted in improvement both subjectively, based on regular feedback from both EPs and Radiologists, and objectively. Conclusion: From this and other quality improvement initiatives, we have learned the importance of engaging frontline practitioners in process changes, specifically the impact on workflow. Also, utilizing existing IT systems and resources can result in positive change with minimal costs.
P086: Accuracy of the Ottawa Ankle Rules when applied by allied health providers in a pediatric emergency department
Authors: MacLellan J. , Smith T. , Baserman J. , Dowling S.
Published: June 2016

Introduction: The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR has been shown to be a reliable rule to exclude fractures in children over 5 years of age. However, there is limited data to support its use by other health care workers in children. Our objective was to determine the sensitivity and specificity of the OAR, to detect clinically significant fractures, when applied by allied health providers (AHPs). Methods: Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Patients assessed by a physician prior to an AHP, presenting for reassessment or >24 hours after the injury, having open, penetrating or neurovascular injury, or multiple injuries were excluded. Patients with metabolic bone disease, a previous x-ray, or the inability to communicate or ambulate before the injury were also excluded. Baseline data on x-ray use was collected in a convenience sample of 100 patients. AHPs then completed an OAR learning module. Then in phase 2, AHPs applied the OAR to a convenience sample of 186 patients. Both AHPs and physicians performed inter-observer assessments. Results: When AHP’s applied the ankle portion of the OAR, the sensitivity was 88% (95% CI 46.7-99.3) and the specificity was 32.5% (95% CI 24.5-41.6) for clinically significant fractures. When AHP’s applied the foot portion of the OAR, the sensitivity was 87.5% (95% CI 46.7-99.3) and the specificity was 15.6% (95% CI 7.0-30.1) for clinically significant fractures. In total, 2 clinically significant fractures (1 foot fracture and 1 ankle fracture) were missed by AHP’s. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.32 for the foot rule. The missed ankle fracture had a positive OAR when performed by a physician as an inter-observer assessment. The missed foot fracture was a distal metatarsal fracture that was outside of the “foot zone” as defined by the OAR. Conclusion: The sensitivity of the OAR when applied by AHP’s was very good. Both clinically significant fractures that were missed by AHP’s would likely have been picked up by a physician assessment. More training and practice using the OAR would likely improve AHP’s inter-observer reliability. Our data suggest the OAR may be a useful tool for AHP’s to apply as a screening tool prior to physician assessment.
P088: British Columbia emergency practitioner workforce and training survey
Authors: Marsden J. , Archibald C. , Christenson J.
Published: June 2016

Introduction: Understanding physician human resources in British Columbia’s (BC) emergency settings is essential to plan for training, recruitment and professional development programs. In 2014 we conducted an online and phone survey to the site leads for the 95 Emergency Departments (ED) attached to hospitals in BC. Methods: A one-page survey was developed by the authors (JC and JM). Each hospital listed on the BC Ministry of Health’s website was contacted to confirm that they had a functioning ED attached to the hospital and to determine who their site lead was. Each ED site lead was then emailed the questionnaire and up to three more follow-up emails and direct phone requests were performed as needed. Results: 92 of the 95 EDs completed the survey and we discovered that just over 1000 physicians deliver emergency care in BC with approximately half doing so in combination with family practice. There was an estimated shortfall of 199 physicians providing emergency care in 2014 and an anticipated shortfall of 287 by 2017 and 399 by 2019. Slightly more than half had formal certification, with 28% through the Royal College of Canada and 70% with the College of Family Physicians of Canada. Conclusion: More than 1000 physicians care for patients in EDs across BC but there is a significant and growing need for more physicians. There is tremendous variation across health authorities in emergency medicine certification, but approximately half of those who deliver emergency care have formal certification. Despite limitations of a survey method, this provides the most accurate and current estimate of emergency practitioner resources and training in BC and will be important in guiding discussions to address the identified gaps.
P089: Frequency of substance abuse in Albertan emergency departments: a retrospective NACRS analysis
Authors: Moe J. , Camargo C. , Jelinski S. , Rowe B.H.
Published: June 2016

Introduction: Substance abuse is strongly correlated with frequent ED use, which is a known risk factor for mortality. This study aimed to examine epidemiologic trends in ED visit frequency, and visit and patient characteristics among all patients presenting to Albertan EDs with visits related to substance abuse over a five-year period. Methods: This is a retrospective analysis of National Ambulatory Care Reporting System (NACRS) administrative ED data for Alberta. All ED visits related to substance abuse made by adults from fiscal year 2010/11 to 2014/15 were included. Using a validated definition enhanced by expert consultation, ED visits were classified as visits related to substance abuse if a set of ICD-10 codes determined a priori were present within the primary or secondary diagnostic fields. Data are reported as means (with SD), medians (with IQR) and proportions. Visit and admission frequencies were compared using Chi square and Chi square trend tests. All analysis was performed using SAS 9.4. Results: Over the study period, 177,287 visits related to substance abuse were made to Alberta EDs. These visits were made by 77,291 unique patients, and annual patient numbers increased consistently from 17,660 in 2010/11 to 24,737 in 2014/15; 62% of patients were male and median age was 38 years (IQR 24, 49). Visits increased from 27,839 in 2010/11 to 42,965 in 2014/15 (p<0.001). 50% arrived by ambulance, and were mostly triaged as CTAS 3 to 5 (32% CTAS 1 or 2, 43% CTAS 3, and 23% CTAS 4 or 5). While most of the patients were discharged, 15.6% of visits resulted in admission; statistical but not clinically meaningful differences were detected in proportions of admitted visits across the study years. Compared to the overall population of patients with substance abuse presentations, frequent presenters (with a visit number greater than the 95th percentile) appeared to be older (median age 40 years [IQR 31, 49]) and had a higher proportion of males (69%). Conclusion: ED presentations for substance abuse increased from 2010 to 2015 in Alberta, and frequent presenters appear to have a different demographic profile. Future study is needed to determine whether patients who present frequently with substance abuse are at increased risk for mortality as this may justify targeted intervention.
P105: Patient outcome feedback in emergency medicine
Authors: Pinto F. , B-Lajoie M.
Published: June 2016

Introduction: Emergency medicine (EM) is characterized by one time patient encounters where the end diagnosis is often unknown. Seeking patient outcome feedback, (POF) which is defined as following a patient’s clinical course once they leave your care, is crucial as it can highlight a discord between an intended verses actual result, thus spurring clinical change. This study seeks to determine whether EM staff and residents currently seek POF, the types of patients followed and the barriers faced. Methods: An online survey was administered to all EM staff and residents (CCFP-EM and FRCP) working at a tertiary academic hospital to determine their current practices and attitudes towards POF. Results: A total of 72 responses were received, of which 41 were residents and 31 were staff, for an overall response rate of 95%. If feedback was sought, the most commonly used tools were looking up imaging results (52%) and talking to EM colleagues (42%). The patients most frequently followed were those with a poor outcome during their ED admission, sick patients with unclear final diagnosis or unplanned returns within 48 hours (55%, 58%, 34% respectively). However, up to 30% of respondents never or rarely sought out POF even in these situations (16%, 19% and 30% respectively). Patients least commonly followed were those where the diagnosis was more certain. Respondents identified many barriers, primarily being time (83%), not being notified about bouncebacks (79%) and remembering which patients to follow (70%). Barriers were amplified for residents as they had a harder time accessing or automatically receiving POF. The most useful tools not currently available, would be being able to easily create electronic tracking lists, being automatically sent discrepant imaging reports and automatic notification of patients who return to the ED within 48hrs. Also, automatic follow up information on patients who experienced a negative outcome or on sick patients with unclear diagnosis is desired. Conclusion: POF is a useful and crucial practice for clinical care, but is currently not often performed. The most commonly used tools are those that are easiest to access, and POF was mainly performed on patients with either negative results or unclear diagnoses. Thus, identifying the types of patients deemed most relevant for receiving POF and addressing the major barriers faced by clinicians can help improve the frequency with which POF is sought, potentially improving patient care.
P109: Identifying patients who may benefit from extracorporeal membrane oxygenation (ECMO) after cardiac arrest in the urban emergency departments of Saskatchewan
Authors: Robinson P. , Sharanowski K. , Lalani N. , Harenberg S. , Lyster K.
Published: June 2016

Introduction: Emergency physician-initiated Extracorporeal Membrane Oxygenation (ECMO/ECPR/ECLS) is gaining critical mass as a successful rescue strategy for patients requiring resuscitation. Wang et al. (2014), Bellezzo et al. (2012) and others have demonstrated promising results of survival to discharge with good neurological function in patients who were resistant to existing treatment protocols after out-of-hospital cardiac arrest. As Saskatchewan does not yet utilize ECMO for cardiac arrest, the objective of this study was to examine the number of adult cardiac arrest patients in the urban emergency departments (EDs) of Saskatchewan who may benefit from the use of ECMO. Methods: Using a retrospective review, we identified 401 patients who died after presenting with cardiac arrest between January 1st, 2013 and December 31st, 2014. Of the original 401, 136 were female and 264 were male, with a mean age of 60.1±20.2 years. The charts of 22 (5.5%) trauma patients were excluded because the suitability of ECMO in these patients is uncertain. Results: For the 379 non-trauma patients, the mean resuscitation length was 41.6±32.8 minutes (median=42 minutes) and 125 of these patients received prehospital mechanical CPR. We applied Bellezzo et al.’s (2012) inclusion and exclusion criteria to identify prospective candidates for ECMO. In total, 53 patients (14.0%) with a mean age of 57.1±13.4 years old, represent suitable candidates for ECMO. 260 (68.6%) were deemed unsuitable either because they failed the inclusion criteria or met explicit exclusion criteria. The remainder (66 [17.4%]) were unsuitable because of age. Conclusion: With 1 in 7 patients potentially representing suitable candidates for ECMO, this is a technique that warrants consideration for implementation in the EDs of Saskatchewan.