bluuebunny/crossref_metadata_2025 huggingface dataset:
P143: The use of the erector spinae plane block to decrease pain and opioid consumption in the emergency department: A literature review
Authors: Abdelhamid K. , ElHawary H. , Turner J.
Published: May 2020

Introduction: Acute pain represents one of the most common reasons for emergency department (ED) visits. In the opioid epidemic that North America faces, there is a significant demand for novel pain control modalities that are both safe and effective. Regional anesthesia techniques have revolutionized perioperative pain management, and they are currently thought to be indicated for acute pain relief in the ED. The erector spinae plane block (ESPB) is a novel regional block that has the ability to block multidermatomal sensation, including cervical, thoracic and lumbar regions, depending on the vertebral level at which the anesthetic is injected along the erector spinae muscle. Under ultrasound guidance, the landmarks involved are easy to identify, and there are no vital structures in the immediate vicinity of the site of injection. By reviewing the literature on ESPB, this review aims to summarize all its indications and efficacy for acute pain management in the ED. Methods: In April 2019, PUBMED, EMBASE, MEDLINE as well as CINAHL databases were systematically searched for articles discussing the use of ESPB in the ED. In compliance with the PRISMA guidelines, the search results were selected against inclusion and exclusion criteria. Due to the novelty of the block, all types of articles were included. Results: Ten studies on 7 different indications have been published on the use of ESPB in the ED. It is currently most commonly used for rib and spine fractures. Other indications include, mechanical back pain, burn injuries, herpes zoster, renal colic, and acute pancreatitis. ESPB was administered at the vertebral level of region of most pain, unilaterally or bilaterally for complete dermatomal block. It was injected as a single or continuous block - in the seated, lateral, or prone position. All of the studies demonstrate a significant reduction in pain. Furthermore, it has been reported to improve respiratory function, and it has not been associated with any complications following administration. Conclusion: This review shows initial data on the promising effect of ESPB in acute pain management in the ED. Current evidence shows its effectiveness and safety for the most common presenting cases of pain, such as rib and spine fracture, mechanical back pain, burn injuries, herpes zoster, renal colic, as well as acute pancreatitis. ESPB is flexible in administration and relatively easy to perform under ultrasound guidance.
PL01: Creation of a risk scoring system for emergency department patients with acute heart failure
Authors: Stiell I. , Perry J. , Clement C. , Sibley S. , McRae A. , Rowe B. , Borgundvaag B. , McLeod S. , Mielniczuk L. , Dreyer J. , Yan J. , Brown E. , Brinkhurst J. , Nemnom M. , Taljaard M.
Published: May 2020

Introduction: Acute heart failure (AHF) is a common emergency department (ED) presentation and may be associated with poor outcomes. Conversely, many patients rapidly improve with ED treatment and may not need hospital admission. Because there is little evidence to guide disposition decisions by ED and admitting physicians, we sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We conducted prospective cohort studies at 9 tertiary care hospital EDs from 2007 to 2019, and enrolled adult patients who required treatment for AHF. Each patient was assessed for standardized real-time clinical and laboratory variables, as well as for SSO (defined as death within 30 days or intubation, non-invasive ventilation (NIV), myocardial infarction, coronary bypass surgery, or new hemodialysis after admission). The fully pre-specified, logistic regression model with 13 predictors (age, pCO2, and SaO2 were modeled using spline functions with 3 knots and heart rate and creatinine with 5 knots) was fitted to the 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions and estimated a sample size of 170 SSOs. Results: The 2,246 patients had mean age 77.4 years, male sex 54.5%, EMS arrival 41.1%, IV NTG 3.1%, ED NIV 5.2%, admission on initial visit 48.6%. Overall there were 174 (7.8%) SSOs including 70 deaths (3.1%). The final risk scale is comprised of five variables (points) and had c-statistic of 0.76 (95% CI: 0.73-0.80): 1.Valvular heart disease (1) 2.ED non-invasive ventilation (2) 3.Creatinine 150-300 (1) ≥300 (2) 4.Troponin 2x-4x URL (1) ≥5x URL (2) 5.Walk test failed (2) The probability of SSO ranged from 2.0% for a total score of 0 to 90.2% for a score of 10, showing good calibration. The model was stable over 1,000 bootstrap samples. Choosing a risk model total point admission threshold of >2 would yield a sensitivity of 80.5% (95% CI 73.9-86.1) for SSO with no change in admissions from current practice (48.6% vs 48.7%). Conclusion: Using a large prospectively collected dataset, we created a concise and sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of this risk scoring scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.
PL03: Thromboembolic events following cardioversion for acute atrial fibrillation and flutter: a systematic review and meta-analysis
Authors: Wong B. , Perry J. , Cheng W. , Zheng B. , Guo K. , Taljaard M. , Skanes A. , Stiell I.
Published: May 2020

Introduction: Several recent observational studies have presented concerning data regarding the safety of cardioversion (CV) for acute atrial fibrillation and flutter (AAFF). We conducted this systematic review to determine whether it is safe to cardiovert AAFF patients without prescribing oral anticoagulation (OAC) post-CV for those who are CHADS-65 negative. Methods: We conducted a librarian assisted search of MEDLINE, Embase, and Cochrane from inception through November 23, 2019. We included observational studies and randomized trials reporting thromboembolic (TE) events (i.e. stroke, transient ischemic attack, or systemic thromboembolism) within 30 days following CV in patients with AAFF, where onset of symptoms was <48 hours. Two reviewers independently screened studies and extracted data. The main outcome was risk of TE events within 30 days post-CV, stratified by OAC use. Risk of bias was assessed with the Quality in Prognostic Studies (QUIPS) tool. The primary analysis was based on prospective studies and the secondary analysis was based on retrospective studies. We performed meta-analyses for TE events where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. We implemented analyses stratified by study design using Open MetaAnalyst and generated the forest plots. Results: Our search yielded 969 titles; 74 were selected for full-text review and 20 studies were included in the review. The primary meta-analysis of 6 prospective studies, including two randomized trials, found a TE event rate of 0.15% (2 TE events/1,314 CVs). Within this prospective group, lack of OAC use was associated with a decreased risk of TE events (RR = 2.15 where RR >1 indicates increased risk of TE events with OAC compared to no OAC; 95% CI 0.50 to 9.31; I2 = 0%). Five of the 6 prospective studies had a low or moderate risk of bias in all QUIPS domains. Secondary meta-analysis of 6 retrospective studies revealed a TE event rate of 0.53% (56 TE events/10,521 CVs). This subgroup showed a trend favouring OAC use with decreased risk of TE events (RR = 0.34 where RR <1 suggests decreased risk of TE events with OAC; 95% CI 0.17 to 0.72; I2 = 0%). Conclusion: In the primary analysis of prospective studies, we found a low TE event rate following CV of AAFF, irrespective of OAC use. This contradicts previous analyses of retrospective studies. Our study supports the longstanding practice of not necessarily prescribing OAC post-CV in the ED for AAFF patients who are CHADS-65 negative.
LO10: Low high-sensitivity troponin concentrations identify low-risk chest pain patients unlikely to benefit from further risk stratification
Authors: Andruchow J. , Boyne T. , Innes G. , Vatanpour S. , Seiden-Long I. , Wang D. , Lang E. , McRae A.
Published: May 2020

Introduction: Very low high-sensitivity troponin-T (hs-cTnT) concentrations on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods: This prospective cohort study enrolled emergency department chest pain patients with non-ischemic ECGs who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3-hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated based on review of medical records and telephone follow-up. Results: Of 1,167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) suffered AMI on the index visit. More than one-third (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5ng/L), which was 94.4% (95%CI 88.8-97.7%) sensitive for 30-day MACE and 99.0% (95%CI 94.5-100%) sensitive for index AMI. Of 292 (25.0%) patients with hs-cTnT < 5ng/L and at least 3-hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%, 95%CI 93.2-100%) and none suffered AMI within 30-days (sensitivity 100%, 95%CI 96.3-100%). Conclusion: Among patients with non-ischemic ECGs and >3-hours since symptom onset, low hs-cTnT concentrations on presentation confer a very low risk of 30-day MACE. In the absence of a high risk clinical presentation, further risk stratification is likely to be low yield.
LO22: Risk-stratification of emergency department syncope by artificial intelligence using machine learning: human, statistics or machine
Authors: Grant L. , Joo P. , Eng B. , Carrington A. , Nemnom M. , Thiruganasambandamoorthy V.
Published: May 2020

Introduction: The Canadian Syncope Risk Score (CSRS) is a validated risk tool developed using the best practices of conventional biostatistics, for predicting 30-day serious adverse events (SAE) after an Emergency Department (ED) visit for syncope. We sought to improve on the prediction ability of the CSRS and compared it to physician judgement using artificial intelligence (AI) research with modern machine learning (ML) methods. Methods: We used the prospective multicenter cohort data collected for the CSRS derivation and validation at 11 EDs across Canada over an 8-year period. The same 43 candidate variables considered for CSRS development were used to train and validate the four classes of ML models to predict 30-day SAE (death, arrhythmias, MI, structural heart disease, pulmonary embolism, hemorrhage) after ED disposition. Physician judgement was modeled using the two variables, referral for consultation and hospitalization. We compared the area under the curve (AUC) for the three models. Results: The proportion of patients who suffered 30-day SAE in the derivation cohort (N = 4030) was 3.6% and in validation phase (N = 2290) was 3.4%. Characteristics of the both cohorts were similar with no shift. The best performing ML model, a gradient boosting tree-based model used all 43 variables as predictors as opposed to the 9 final CSRS predictors. The AUC for the three models on the validation data were: best ML model 0.91 (95% CI 0.87–0.93), CSRS 0.87 (95% CI 0.83–0.90) and physician judgment 0.79 (95% CI 0.74 - 0.84). The most important predictors in the ML model were the same as the CSRS predictors. Conclusion: A ML model developed using AI method for risk-stratification of ED syncope performed with slightly better discrimination ability though not significantly different when compared to the CSRS. Both the ML model and the CSRS were better predictors of poor outcomes after syncope than physician judgement. ML models can perform with similar discrimination abilities when compared to traditional statistical models and outperform physician judgement given their ability to use all candidate variables.
LO24: Implementing emergency department take-home naloxone programs: a systematic scoping review
Authors: Koh J. , O'Brien D. , Slater L. , McLaughlin K. , Hyshka E.
Published: May 2020

Introduction: Distributing take-home naloxone (THN) kits from Emergency Departments (EDs) is an important strategy for preventing opioid overdose deaths. However, there is a lack of clear operational guidance for implementing ED-based THN programs. This scoping review had two objectives: 1) identify key strategies for THN distribution in EDs, and 2) develop a theory-informed implementation model that can be used to optimize the effectiveness of ED-based THN programs. Methods: We systematically searched health science databases through April 18, 2019. The search strategy combined terms representing the ED, naloxone, and take-home kits/bystander administration. Two reviewers independently screened the search results. We included all peer-reviewed articles that described THN distribution within EDs. A standardized form was used for data extraction. Included studies were coded by two reviewers and mapped to domains of the Consolidated Framework for Implementation Research (CFIR). A third reviewer with content expertise adjudicated disagreements in record screening and data coding. Results: Database searching retrieved 717 records after duplicates were removed. 87 full-text studies were assessed for eligibility. Two studies were added through other sources, resulting in a total of 21 studies included in the final review. Of note, 14 studies evaluated existing ED-based THN programs. We synthesized themes that emerged within each CFIR domain and identified four key implementation strategies: 1) develop ED policies on opioid harm reduction; 2) collaborate with community and government partners to ensure programs meet patient needs; 3) address provider attitudes and knowledge gaps through dedicated training; and 4) establish guidelines to identify patients who are at risk of opioid overdose, and engage at-risk patients to maximize THN acceptance. Conclusion: ED-based THN programs must be tailored to local community needs and available hospital resources. Innovative implementation strategies are needed to promote ED provider engagement, and reduce barriers to patient acceptance of THN in the ED. This scoping review highlights key considerations for ED-THN implementation that can guide EDs to establish new programs, or refine existing programs to maximize their effectiveness.
LO26: The mean abnormal response rates of laboratory tests ordered in the emergency department: shooting percentage insights from a multicentre study
Authors: Enwere E. , Wang D. , Guo M. , Naugler C. , Lang E.
Published: May 2020

Introduction: There is ongoing concern about the burden placed on healthcare systems by lab tests. Although these concerns are widespread, it is difficult to quantify the extent of the problem. One approach involves use of a metric known as the Mean Abnormal Response Rate (MARR), which is the proportion of tests ordered that return an abnormal result; a higher MARR value indicates higher yield. The primary objective of this study was to calculate MARRs for tests ordered between April 2014 and March 2019 at the four adult emergency departments (EDs) covering a metropolitan population of 1.3 million. Secondary objectives included identifying tests with highest and lowest MARRs; comparison of MARRs for nurse- and physician-initiated orders; correlation of the number of tests per order requisition to MARR; and correlation of physician experience to MARR. Methods: In total, 40 laboratory tests met inclusion criteria for this study. Administrative data on these tests as ordered at the four EDs were obtained and analyzed. Multi-component test results, such as from CBC, were consolidated such that an abnormal result for any component was coded as an abnormal result for the entire test. Repeat tests ordered within a single patient visit were excluded. Physician experience was quantified for 209 ED physicians as number of years since licensure. Analyses were descriptive where appropriate for whole-population data. Risk of bias was attenuated by the focus on administrative data. Results: The population dataset comprised 33,757,004 test results on 415,665 unique patients. Of these results, 30.3% were the outcomes of nurse-initiated orders. The 5-year MARRs for the four hospitals were 38.3%, 40.0%, 40.7% and 40.9%. The highest per-test MARRs were for BNP (80.5%) and CBC (62.6%), while the lowest were for glucose (7.9%) and sodium (11.6%). MARRs were higher for nurse-initiated orders than for physician-initiated orders (44.7% vs. 38.1%), likely due to the greater order frequency of high-yield CBC in nurse-initiated orders (38.6% vs. 18.1%). The number of tests per order requisition was inversely associated with MARR (r = -0.90, p < 0.001). Finally, the number of years since licensure was modestly but significantly associated with MARR (r = 0.28, p < 0.001). Conclusion: This is the first and largest study to apply the MARR in an ED setting. As a metric, MARR effectively identifies differences in test ordering practices on per-test and per-hospital bases, which could be useful for data-informed practice optimization.
LO27: Relevance of Choosing Wisely Canada non-emergency medicine specialty lists to emergency medicine practice
Authors: Upadhye S. , Davies-Schinkel C. , Pilakka S.
Published: May 2020

Introduction: The Choosing Wisely Canada (CWC) initiative is dedicated towards optimizing patient care and reduce unnecessary resource use. Different specialty organizations create recommendations lists towards these outcomes. The goal of this study was to examine the applicability of non-Emergency Medicine (EM) recommendations towards EM practice. Methods: The entire master recommendations listings spreadsheet was downloaded from the CWC website (March 2019; n = 333). The EM-specific items from the CAEP checklist were deliberately excluded (n = 10). Items were rated by Niagara community EM physicians (n = 7) using the previously validated Best Evidence in Emergency Medicine (BEEM) rating scale (7 point Likert scale) to determine potential impact on EM practice. Items rated “6 or 7/7” were determine as “high relevance.” Redundant items were consolidated. Results: From the retrieved CWC master list, a total of 102 “highly relevant” recommendations were identified (41 items scored 6/7 [12%], 61 scored 7/7 [18%]; total 31%). Redundant items consolidated included antimicrobial avoidance (n = 18), opioid avoidance for pain (n = 11), reduction of unnecessary imaging (n = 11), and avoidance of routine low back imaging (n = 7). Conclusion: There are a large number of non-EM specialty recommendations highly relevant to EM practice in the CWC database (31%). Quality improvement initiatives looking to operational CWC recommendations in Canadian Emergency Departments should be aware of these as a part of optimizing patient care.
LO31: Triage drift: Variation in application of the Canadian Triage Acuity Scale between triage nurses compared to triage paramedics in response to overcrowding pressures in an emergency department
Authors: Kovacs M. , Campbell S.
Published: May 2020

Introduction: CTAS is a validated five-level triage score utilized in EDs across Canada and internationally. Moderate interrater reliability between prehospital paramedic and triage nurse application of CTAS during clinical practice has been found. This study is the first assessment of the variation in distribution of CTAS scores with increasing departmental pressure as measured by the NEDOCs scale comparing triage allocations made by triage nurses with those made by triage paramedics. Methods: We conducted a retrospective, observational cohort study of EDIS data of all patients triaged in the Halifax Infirmary Emergency Department from January 1, 2017-May 30, 2017 and January 1, 2018 - May 30, 2018. CTAS score assignment by nursing and paramedic triage staff were compared with increasing levels of ED overcrowding, as determined by the department NEDOCS score. Results: Nurses were more likely to assign higher acuity scores in all situations of department crowding; there was a 3% increased probability that a nurse, as compared to a paramedic, would triage as emergent when the ED was not overcrowded (Pearson chi-square(1) = 4.21, p < 0.05, Cramer's v = 0.028, n = 5314), and a 10% increased probability that a nurse, as compared to a paramedic, would triage a patient as emergent when EDs were overcrowded (Pearson chi-square(1) = 623.83, p < 0.001, Cramer's v = 0.11, n = 56 018). Conclusion: Increasing levels of ED overcrowding influence triage nurse CTAS score assignment towards higher acuity to a greater degree than scores assigned by triage paramedics.
LO32: Artificial intelligence to predict disposition to improve flow in the emergency department
Authors: Grant L. , Xue X. , Vajihi Z. , Azuelos A. , Rosenthal S. , Hopkins D. , Aroutiunian R. , Unger B. , Guttman A. , Afilalo M.
Published: May 2020

Introduction: Emergency department (ED) crowding is a major problem across Canada. We studied the ability of artificial intelligence methods to improve patient flow through the ED by predicting patient disposition using information available at triage and shortly after patients’ arrival in the ED. Methods: This retrospective study included all visits to an urban, academic, adult ED between May 2012 and June 2019. For each visit, 489 variables were extracted including triage data that had been collected for use in the Canadian Triage Assessment Scale (CTAS) and information regarding laboratory tests, radiological tests, consultations and admissions. A training set consisting of all visits from April 2012 up to December 2018 was used to train 5 classes of machine learning models to predict admission to the hospital from the ED. The models were trained to predict admission at the time of the patient's arrival in the ED and every 30 minutes after arrival until 6 hours into their ED stay. The performance of models was compared using the area under the ROC curve (AUC) on a test set consisting of all visits from January 2019 to June 2019. Results: The study included 536,332 visits and the admission rate was 15.0%. Gradient boosting models generally outperformed other machine learning models. A gradient boosting model using all available data at 2 hours after patient arrival in the ED yielded a test set AUC 0.92 [95% CI 0.91-0.93], while a model using only data available at triage yielded an AUC 0.90 [95% CI 0.89-0.91]. The quality of predictions generally improved as predictions were made later in the patient's ED stay leading to an AUC 0.95 [95% CI 0.93-0.96] at 6 hours after arrival. A gradient boosting model with 20 variables available at 2 hours after patient arrival in the ED yielded an AUC 0.91 [95% CI 0.89-0.93]. A gradient boosting model that makes predictions at 2 hours after arrival in ED using only variables that are available at all EDs in the province of Quebec yielded an AUC 0.91 [95% 0.89-0.92]. Conclusion: Machine learning can predict admission to a hospital from the ED using variables that area collected as part of routine ED care. Machine learning tools may potentially be used to help ED physicians to make faster and more appropriate disposition decisions, to decrease unnecessary testing and alleviate ED crowding.
LO36: Reducing emergency department bloodwork and eliminating waste
Authors: Sheps R. , Antoniu V. , Saraga S. , Soong C. , Wilde-Friel G. , Dushenski D.
Published: May 2020

Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures & Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.
LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway)
Authors: Kirwan C. , Ramsden S. , Kibria A. , Carter J. , Tong X. , Huang J. , McArthur R. , Clayton N. , de Wit K.
Published: May 2020

Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.
LO41: The development of a standardized provincial massive hemorrhage protocol with a built-in continuous quality improvement framework
Authors: Yeh C. , Cope S. , Thompson T. , McGilvray S. , Petrosoniak A. , Chin V. , Karkouti K. , Nathens A. , Murto K. , Beno S. , McDonald A. , Beckett A. , Hanif H. , Collins A. , Nascimento B. , Rizoli S. , Sholzberg M. , Pavenski K. , Callum J.
Published: May 2020

Background: Massive hemorrhage protocols (MHPs) streamline the complex logistics required for prompt care of the bleeding patient, but their uptake has been variable and few regions have a system to measure outcomes from these events. Aim Statement: We aim to implement a standardized MHP with uniform quality improvement (QI) metrics to increase uptake of evidence-based MHPs across 150-hospitals in Ontario between 2017 and 2021. Measures & Design: We performed ongoing PDSA cycles; 1) stakeholder analysis by surveying the Ontario Regional Blood Coordinating Network (ORBCoN), 2) problem characterization and Ishikawa analysis for key QI metrics based on areas of MHP variability in 150 Ontario hospitals using a web-based survey, 3) creation of a consensus MHP via a modified Delphi process, 4) problem characterization at ORBCoN for the design of a freely available toolkit for provincial implementation by expert working groups, 5) design of 8 key QI metrics by a modified Delphi process, and 6) identification of process measures for QI data collection by implementation metrics. Evaluation/Results: PDSA1-2; 150-hospitals were surveyed. 33% of hospitals lacked MHPs, mostly in smaller sites. Major areas for QI were related to activation criteria, hemostatic agents, protocolized hypothermia management, variable MHP naming, QI metrics and serial blood work requirements. PDSA3; 3 Delphi rounds were held to reach 100% expert consensus for 42 statements and 8 CQI metrics. Major areas for modification were protocol name, laboratory resuscitation targets, cooler configurations, and role of factor VIIa. PDSA4; adaptable toolkit is under development by the steering committee and expert working groups. Implementation is scheduled for Spring 2020. PDSA5; the 8 CQI metrics are: TXA administration < 1 h, RBC transfusion < 15 min, call to transfer for definitive care < 60 min, temp >35°C at end of protocol, Hgb kept between 60-110g/L, transition to group-specific RBC by 90 min, appropriate activation defined by ≥6 units RBC in the first 24 hours, and any blood component wastage. Discussion/Impact: MHP uptake, content, and tracking is variable. A standardized MHP that is adaptable to diverse settings decreases complexity, improves use of evidence-based practices, and provides a platform for continuous QI. PDSA6 will occur after implementation; we will complete an implementation survey, and design a pilot and feasibility study for prospective tracking of patient outcomes using existing prospectively collected inter-hospital and provincial databases.
Nonelectoral Participation in Deeply Divided Societies: Transforming Consociations from the Ground Up?
Authors: Agarin Timofey
Published: May 2020

Premised on elite accommodation, consociations provide little consideration for citizens’ input on institutional change. Likewise, valuable analyses of cross-community political participation in divided societies have emerged in recent years, yet whether the relationship between the grassroot and formal political process has broader consequences remains to be fully explored. The article examines the conditions in which nonelectoral participation takes place and the ways in which actors involved therein negotiate constraints for continuous cross-community mobilization. The structure of political systems and the nature of deep divisions in Northern Ireland and Federation of Bosnia-Herzegovina invite a comparison of the consequences of nonelectoral political participation in these two illustrative case studies. The article concludes that while the formal political context shapes the likelihood of engagement on a cross-community basis, whether nonelectoral participation changes the structure of political decision-making depends on the willingness and ability of those involved to cooperate with formal institutional politics.
SUMS OF PARTIAL THETA FUNCTIONS THROUGH AN EXTENDED BAILEY TRANSFORM
Authors: EL BACHRAOUI MOHAMED
Published: May 2020

In this note, we evaluate sums of partial theta functions. Our main tool is an application of an extended version of the Bailey transform to an identity of Gasper and Rahman on $q$-hypergeometric series.
Functional assessments in the UK social security system: the experiences of claimants with mental health conditions
Authors: PYBUS KATIE , PICKETT KATE. E. , LLOYD CHARLIE , PRADY STEPHANIE , WILKINSON EMERITUS RICHARD
Published: May 2020

Eligibility for health-related income benefits in the United Kingdom is now determined through the use of functional assessments conducted by healthcare professionals. Claimant satisfaction with both Personal Independence Payment (PIP) and Work Capability Assessments (WCA) has been mixed and concerns have been raised that mental health conditions are not well-understood in this context, but academic research has so far been limited. Individuals with a range of common mental disorders and severe mental illness were interviewed (n=18) about their experiences of undergoing eligibility assessments for health-related income benefits. Data were analysed using a thematic analysis approach.

Eleven out of the 18 participants had been turned down for one or more income benefits and successful claims were more likely where supported by health and care professionals. Eligibility assessments were overwhelmingly perceived as focusing on physical health with limited scope to explore the impact of mental health on functioning. Evidence from this and other studies suggests that improvements are needed to the eligibility assessment process for all claimants but particularly those with a mental health condition.
World Food Politics
Authors: Alexander William M.
Published: May 2020

After years of teaching Development Administration for, our Master of International Agriculture program at California Polytechnic, I worked for two years directly with subsistence farmers in Africa. That experience forced me to conclude that this generation of Cal Poly graduates must learn how they, acting with others, can alleviate hunger in the late-developing countries, especially in Agriculture, Architecture and Engineering. New knowledge about available resources, about people and their natural increase, and about production and distribution of food combine to show that starvation is not necessary. Like slavery and smallpox, hunger can be eliminated from the face of the earth.
Evaluating Manuscripts in Political Science
Authors: Fisher Phyllis
Published: May 2020

A developmental review is a request for advice from experts and potential adopters of the book. Basically, we ask the reviewer to help us evaluate and shape the manuscript by telling us honestly and directly what's good about it and what's not so good.

We commission three kinds of reviews.

We occasionally ask well known scholars to serve as expert advisors, providing bibliographies, abstracts of articles, and outlines. They read draft chapters and then reread them. The point of their efforts is to help a nonexpert author gain expertise. Remuneration is generous by publishing standards: about $500 per chapter. The expert advisor can expect to have his or her name associated with the book when it's published. This kind of reviewing is relatively rare in political science.

In another kind of expert review, we ask specialists to prepare outlines and provide bibliographies and do one careful reading. The fee is usually $250 per chapter.
A Legislative Case Study Assignment
Authors: Winder David W.
Published: May 2020

In an article entitled “Teaching the Congress and Legislative Process Courses,” L. Sandy Maisel found by examining the syllabi of such courses that about half of them involved legislative case study assignments. He suggested that further exploration of these assignments would be appropriate. Since students are so commonly required to do case studies of bills in legislative courses, a description of this type of assignment and discussion of how to implement it would be useful. In this paper, I will cover my use of this type of assignment in a course on the legislative process. In describing this legislative case study requirement, sections on background information, the case study assignment, and student reaction to the assignment, together with a brief conclusion, will be presented.
Clusters of Power and Influence in American Society
Authors: Rouse John E.
Published: May 2020

In teaching political science courses in American government, public policy, and public administration, students have considerable difficulty in conceptualizing the complexity of the two essential values of democratic capitalism.

Those values are equality, espousing the values of democracy, and efficiency, depicting the rationale of capitalism.

The purpose of this brief essay is to conceptualize more clearly the setting of the infrastructure of public and private relations in the United States. These clusters of power and influence will enable students to comprehend more easily the dynamics of political economy in the United States.
Role Playing in Teaching Public Administration
Authors: Duncomb Sidney
Published: May 2020

How do you teach a student of public administration how to make a management study or examine a budget in a classroom setting? How do you give a rural Idaho student a sense of the tensions, conflicts, and problems of a major metropolitan area without having lived in that area? How do you dramatize the logical consequences of administrative theorists in a humorous manner that reinforces learning? Role-playing and role-playing drama have been used by the author over the past decade to accomplish each of these objectives.
Enlivening Classrooms with Personal Subscriptions
Authors: Barber Charles T.
Published: May 2020

As a lively discipline, political science meshes well with the print media. Coverage of recent events by newspapers and magazines can be an outgoing part of the classroom experience. Encouraging students to get personal subscriptions points them toward greater involvement in the learning process.

My initial use of media revolved around single issues of journals in combination with texts. For Introduction to International Relations, I ordered the latest Foreign Affairs and for International Law, I included the most recent American Journal of International Law. One of my best finds, a special issue of International Organization devoted to Canada, rounded out coverage for a special topics seminar on Canada. Student personal copies of journals, sometimes tied to student memberships, proved rewarding in helping juniors and seniors to learn.
Introducing C-SPAN's Resources for Teaching
Authors: Frantzich Stephen E.
Published: May 2020

Integrating C-SPAN coverage into a traditional course provides some unique opportunities and burdens. On the opportunity side, the ability to see the subject matter relatively directly sparks interest, verifies class material and allows for some creative activities not possible using traditional resources. On the more negative side, the approaches outlined in this paper do not necessarily make teaching easier. Since faculty seldom have the opportunity to become C-SPAN “junkies” watching all the coverage, students will bring questions and examples to class which challenge the instructor more than the material stimulated by contact with traditional written sources. In evaluating many of the exercises, the instructor will have to rely on the student's interpretation and the quality of data selection and analysis. Grading will more often be based on how well the student makes his case, rather than the instructor knowing the contours of what the student should conclude ahead of time.
Congress: The Legislative Process
Authors: Frantzich Stephen E.
Published: May 2020

This annotated syllabus outlines a procedure for integrating televised coverage of the U.S. Congress into a regular course on the U.S. Congress or the legislative process. The first section is a facsimile of the syllabus students would receive. A number of suggested assignments are included from which the faculty or students would have to choose. The appendices describe the written assignments in detail. The course begins with the premise that introducing television coverage of Congress can augment traditional methods making the educational experience better, but it is not a replacement for the faculty member of a panacea for a poorly designed or implemented course.
Reporting on Washington From Back Home
Authors: Wolfson Lewis W.
Published: May 2020

Americans are increasingly concerned about the federal government's impact in their lives. While the news media inform us more fully about government these days, it is not always easy to grasp what ‘those people in Washington’ really do and why they do it, or how that affects what happens back home.

C-SPAN has opened a window onto Washington, providing journalists a unique opportunity to learn more about the system. Some observers say television shows mostly staged political rituals. But it still offers a view of the federal government that few Americans have had a chance to see. You can cover debate of policy issues that may affect thousands of people in your area and millions more nationally. You can watch our political leaders being tested. You can report on hearings and symposia that help set the agenda for policymaking and legislation.
Pre-Professional Training in Public Administration
Authors: Hudson William E.
Published: May 2020

Does the improvement of pre-professional training at an undergraduate college come at the expense of general education in the liberal arts and sciences? Does the introduction of public administration courses and programs threaten the integrity of the political science curriculum? Increasingly, liberal arts colleges have had to address these questions as students have demanded more "practical" training as a part of their undergraduate education. Within political science departments, these questions are usually raised in the context of expanding public administration offerings. In the last few years, at Providence College, we have introduced a new Public Administration Program which has significantly improved our students preparation for public sector employment in a way that is compatible with our general political science curriculum.
Careers of Political Science Majors
Authors: Barber Kathleen L.
Published: May 2020

Why major in political science? This is a question students often ask. Under the pressure of vocationalism, students in the liberal arts are increasingly searching for connections between their undergraduate major and the world of work. This is a concern not only of students, but necessarily of faculty and institutional planners. Anxiety about enrollment shifts from the liberal arts to vocational training has inspired foundation-funded programs to assess strategies for relating traditional learning to career preparation. At a recent major conference on the humanities and careers in business, corporate and academic leaders urged colleges and universities to pursue excellence in the humanities “without distortion and without faddish ‘relevance’ to business.” At the same time, the need to assist students with career planning of a more comprehensive nature than mere job placement was acknowledged.
Why Teach About Congress
Authors: Davidson Roger
Published: May 2020

Political scientists' long-standing love affair with the United States Congress no doubt baffles people outside the profession. By the same token, the popularity of courses on Congress is not fully understood. Articles and monographs on the subject pour out at a phenomenal rate, and students receive unique benefits from courses on the subject year after year. Still the question is posed: Why so much attention to the U.S. Congress?

Much of the puzzlement arises from Congress's persistent image problem. The other branches of government have nothing quite like the comic image of Senator Snort, the florid and incompetent windbag, or Congressman Bob Forehead, the bland and media-driven founder of the "JFK Look-Alike Caucus." Pundits and humorists — from Mark Twain and Will Rogers to Johnny Carson, from Thomas Nast to Garry Trudeau — find Congress an inexhaustible source of raw material. Running down Congress, it seems, is a leading national pastime.
News and News Making in the Study of Politics
Authors: Hedblom Milda K.
Published: May 2020

Several political Scientists, philosophers, English and speech specialists, legal specialists, and even one geographer recently gathered to discuss and consider how to teach news and new-making at the third annual “Classroom and the Newsroom” seminar sponsored by the Modern Media Institute and The Poynter Center, Indiana University with Ford Foundation funding. It was an excellent opportunity for us to discuss news theory, criticism, and pedagogy among ourselves and with prominent broadcast/print journalists and media scholars.Various local media organizations provided special tours or meetings, and most interesting of all, access as observers to working sessions.

Apart from discussion of news theory and classroom technique an extenseive bibliography for books, films and video tapes about news and news media was available to seminar participants. An abbreviated list indicating those materials likely to be most directly useful to political scientists follows.
New Jersey: A Reference Guide & Course Syllabus
Authors: Lehne Richard
Published: May 2020

New Jersey is a fascinating state, and New Jersey politics is a fascinating business. The state is Newark, Camden, Jersey City, and aging urban areas typical of the northeast. New Jersey is also the Pinelands preserve, a fragile environmental area the size of Rhode Island protected by the state from indiscriminate development. New Jersey is the expansive beaches of the Jersey shore, the rugged beauty of the Delaware River Water Gap, and comfortable patrician estates whose owners continue to devote weekends to fox-hunting. New Jersey is valuable farmlands which still make New Jersey the Garden State, and it is the Hackensack Meadowlands, the Sports Complex and Atlantic City as well. New Jersey is a diverse state, and its political life reflects both that diversity as well as the state's changing political traditions and developing political institutions.