bluuebunny/crossref_metadata_2025 huggingface dataset:
P023: La valeur diagnostique du ‘Score de détection de la dissection aortique’ et du ratio neutrophiles sur lymphocytes pour le syndrome aortique aigu
Authors: Cournoyer A. , Langlois-Carbonneau V. , Daoust R. , Chauny J.
Published: May 2018

Introduction: Le syndrome aortique aigu (SAA) est une condition rare et généralement mortelle qui demeure difficile à diagnostiquer. Le Score de détection de la dissection aortique (DDA) et le ratio de neutrophiles sur lymphocytes (NL) ont été proposés comme des éléments pouvant contribuer à exclure le diagnostic du SAA. Lobjectif primaire de cette étude est de déterminer la valeur diagnostique (sensibilité et spécificité et rapport de vraisemblance négatif [RV-]) de ces deux éléments de façon indépendante et combinée chez les patients suspectés de SAA au département durgence. Methods: Les patients ayant subi une angiographie par tomodensitométrie (angioCT) à la recherche dune dissection aortique entre 2008 et 2014 à lurgence dun hôpital tertiaire montréalais ont été inclus dans cette étude de cohorte rétrospective. Le score DDA a été établi à partir des dossiers médicaux et le ratio NL calculé à partir de la première formule sanguine prélevée chez ces patients. Pour le score DDA, un score de 1 ou plus et de 2 ou plus ont été évalués comme seuils de positivité. Pour le ratio NL, une valeur de plus de 4,6 a été choisie comme seuil puisquil sagissait du ratio proposé afin de différencier les patients atteints dun SAA de ceux souffrant dun anévrysme chronique. Pour lévaluation de la combinaison des deux tests, afin de maximiser la sensibilité, un score DAA de 1 ou plus ou un ratio NL de plus de 4,6 serait considéré comme positif. Le test de référence pour tous les patients était langiographie par tomodensitométrie. À partir de cela, la sensibilité, la spécificité et le rapport de vraisemblance négatif de chacun de ces tests/combinaison de tests et leurs intervalles de confiance (IC) ont été calculés. Results: Un total de 198 patients (99 hommes et 99 femmes) dun âge moyen de 63 ans (±16) ont été inclus dans létude, parmi lesquels 26 (13%) souffraient dun SAA. Un score DDA de 1 ou plus avait une sensibilité de 84,6% (IC 95% 65,1-95,6), une spécificité de 65,7% (IC 95% 58,1-72,8) et un VR- de 0,23 (IC 95% 0,09-0,58). Un score DDA de 2 ou plus avait une sensibilité de 23,1% (IC 95% 9,0-43,7), une spécificité de 95,3% (IC 95% 91,0-98,0) et un VR- de 0,81 (IC 95% 0,65-1,00). La sensibilité dun ratio NL de plus de 4,6 était de 42,3% (IC 95% 23,4-63,1), la spécificité de 58,7% (IC 95% 51,0-66,3) et le VR- de 0,98 (0,69-1,40). La combinaison du score DDA et du ratio NL avait une sensibilité de 88,5% (IC 95% 69,9-97,6), une spécificité de 38,4% (IC 95% 30,9-46,0) et un VR- de 0,30 (IC 95% 0,10-0,89). Conclusion: Avoir un score de DDA inférieur à 1 diminue significativement les chances davoir un SAA, nélimine pas cette possibilité et ne devrait pas être utilisé, sauf chez les patients ayant une probabilité pré-test déjà très faible. Le ratio NL en utilisant un seuil de 4,6 na aucune utilité diagnostique pour le SAA.
P031: An online video analysis study of out of hospital cardiac arrest: patterns in presentation and opportunities for machine learning
Authors: Douma M. J.
Published: May 2018

Introduction: Cameras are a common in public spaces. London England is estimated to have 500,000 and Beijing China over 800,000. Smartphone penetration exceeds 60% of the population in 20 countries worldwide. Hundreds of sudden cardiac arrests are captured on video annually. This study searches publically available cardiac arrest videos with two objectives i) describe sudden cardiac arrest behaviour and ii) explore potential opportunities for machine learning. Methods: The search terms: “sudden death”, “heart attack”, “cardiac arrest” and “public death” were used. English sources included: Youtube.com, Dailymotion, vimeo.com, vidamax.com, LiveLeak.com and documentingreality.com Whereas, iqiyi.com, youku.com, le.com, fun.tv, pptv.com and tudou.com were searched using simplified Chinese. Inclusion criteria required that the subject in the video be completely visible five seconds prior to the event and at least ten seconds after and the quality of the video be adequate to visualize movement. Exclusion criteria included trauma or precipitating event (substance misuse, toxic exposure or asphyxiation). Each video source was searched until 30 consecutive irrelevant videos were obtained. Results: Four hundred and eighty eight videos met inclusion criteria. Of those videos, 112 could be confirmed as a “cardiac arrest” by at least two sources (news, or family social media account). In 53 (47%) of these videos the person touches their face or head within five seconds of collapse. Of the 98 videos where the person is upright, in 41 (37%) instances they hip-flexes and with their hands on their upper legs prior to collapse. This pattern of behaviour is combined in 36 (32%) instances. After collapse, 68 (61%) appeared to exhibit extension posturing activity. Agonal breathing was visible in 39 instances (35%). Conclusion: Sudden out of hospital cardiac arrest has a recognizable pattern. This represents an opportunity for machine learning, using shape tracking and edge detection, to recognize this event and activate the emergency response system.
P032: Twelve angry medics: a study of bimanual external aortic compression in healthy adult men
Authors: Douma M. J. , Brindley P.
Published: May 2018

Introduction: Following life-threatening hemorrhage the goal is to temporize blood-loss and expedite definitive-rescue. Junctional (abdominal-pelvic) trauma, between the inguinal ligament and umbilicus; is a leading cause of potentially survivable mortality. Numerous devices such as junctional tourniquets and resuscitative endovascular balloon occlusion of the aorta have been suggested for this injury pattern, but we propose an immediately available and expedient bimanual maneuver that may act as a bridge to device application, proximal external aortic compression (PEAC). Of note, external aortic compression has been used for centuries in life-threatening postpartum hemorrhage. Methods: Twelve paramedic volunteers were recruited from a continuing education event. Participant demographics, blood pressure, abdominal circumference, body mass index and procedural discomfort were recorded. In pairs, six participants were taught PEAC and performed the maneuver, then exchanged roles. Training consisted of researcher led demonstration and participant return demonstration with feedback. The duration of training was less than five minutes for all participants. Femoral artery hemostasis was measured by doppler ultrasound. Results: Participant mean age was 28.6 (range 22 to 46) and their mean systolic blood pressure was 128.25 mmHg (range 102 to 145). Mean body mass index was 24 (range 22 to 28) and abdominal girth was 80 cm (range 70 to 110). Bilateral common femoral artery blood flow became undetectable in all participants, by doppler ultrasound. Participant discomfort was reported as a mean of 4.4 (range 3 to 6) on a zero to ten scale. No complications were reported with seven and 30 days follow-up. Conclusion: This study demonstrates successful PEAC in twelve healthy participants. However, our limitations include a small sample and the relatively modest abdominal circumferences of our participants. If light of these limitations, PEAC may be a potentially life-saving maneuver which is immediately deployable and easy to learn, for patient temporization until device application and/or operative rescue.
P044: Register to donate while you wait: assessing public acceptability of utilizing the emergency department waiting room for organ and tissue donor registration
Authors: Ellis B. , Perry J.J. , Hartwick M.
Published: May 2018

Introduction: Our study objectives were to assess the acceptability of using the emergency department (ED) waiting room to provide knowledge on, and offer opportunities for organ and tissue donor registration; and to identify barriers to the donor registration process in Ontario. Methods: We conducted a paper based in-person survey over nine days for eight hour blocks in March and April 2017. The survey instrument was created in English using existing literature and expert opinion, pilot tested and then translated into French. The study collected data from patients and visitors in an urban academic Canadian tertiary care ED waiting room. All adults in the waiting room were approached to participate during the study periods. Individuals waiting in clinical care areas were excluded, as well as those who required immediate treatment. Results: The number of attempted surveys was 324; 67 individuals (20.7%) refused to partake. A total of 257 surveys were distributed and five were returned blank. This gave us a response rate of 77.8% with 252 completed surveys. The median age group was 51-60 years old with 55.9% female. Forty-six percent were Christian (46.0%) and 34.1% did not declare a religious affiliation. Nearly half of participants (44.1%) were registered organ donors. The majority of participants agreed or were neutral (83.3%) that the ED waiting room was an acceptable place to provide information on organ and tissue donation. Further, 82.1% agreed or were neutral that the ED was an acceptable place to register as an organ donor. Nearly half (47.2%) agreed that they would consider registering while in the ED waiting room. A number of barriers to registering as an organ and tissue donor were identified. The most common were: not knowing how to register (22.0%), a lack of time to register (21.1%), and having unanswered questions regarding organ and tissue donation (18.7%). Conclusion: Individuals waiting in the ED are supportive of using the ED waiting room for distributing information regarding organ and tissue donation, and facilitating organ and tissue donation registration. Developing such a practice could help to reduce some of the identified barriers, including a lack of time and having unanswered questions regarding donation.
P049: Changes in situational awareness of emergency teams in simulated trauma cases using an RSI checklist
Authors: French J.P. , Maclean D. , David K. , McCoy A. , Benjamin S. , Fraser J. , Pishe T. , Atkinson P.
Published: May 2018

Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.
P051: Management of subcutaneous abscesses in the emergency department
Authors: Friedman S.M. , Al-Den A. , Porplycia D.
Published: May 2018

Introduction: We sought to characterize the management of uncomplicated subcutaneous abscesses (SA) by Canadian emergency physicians (EPs). Methods: Cross-sectional study of CAEP membership. Subjects were emailed an invitation to an online survey, and two biweekly reminders. Wilcoxon rank sum test was used for association with age, and Chi Square and Fischers exact test were used for binary variables. Results: Response rate was 21.2 % (392 Reponses / 1850 surveyed). Duration of practice ranged from 30.2 % practising <= 5 years, to 25.7% practising >= 20 years. Teaching setting was described in 89.1% of responses. Irrigation with saline is performed by 57.1 % of EPs, tap water 2.1 %, or disinfectant 2.1% of EPs, with 39.1% not doing any irrigation. Approximately half (49.2%) typically do not pack or close wounds, while 40.6 % employ ribbon or gauze packing, and 1.6 % primary closure. Antibiotics are generally not prescribed by 16.8%. EPs prescribe antibiotics when suspecting surrounding cellulitis (84.2%), immunocompromised host (51.6%), MRSA (28.9%), or recurrence within 30 days (27.5 %). Cultures are taken almost always by 28.2%, half the time or less by 33.9%, never by 11.6%, and if MRSA is suspected by 33.9%. Follow-up instructions are with FP (56.7%), ED at 24 hours (5.91 %) or 48 hours (17.74 %), or not required (24.7%). Most EPs (90.9%) report having no standardized protocol for abscess management in their ED. EPs with fewer years in practice are more likely to make cruciate incisions (p=0.009), to generally not irrigate incisions (p=0.02), to culture if MRSA is suspected (p=0.02), and to prescribe antibiotics when suspecting MRSA (p=0.02) immune-compromised host (p=0.03), and in case of spontaneous treatment failure or recurrence (p=0.0004). EPs with more years in practice are more likely to pack with ribbon gauze (p=0.06), and to almost always swab for C&S (p=0.04) Conclusion: Practice variability and deviations from practice guidelines (i.e. IDSA, Choosing Wisely Canada) are noted. A knowledge translation exercise based on the guidelines for Canadian EPs would be useful.
P053: Characteristics and outcomes of patients seen by transition coordinators in the emergency department
Authors: Gaudet L.A. , Krebs L.D. , Couperthwaite S. , Kruhlak M. , Loewen N. , Zilkalns E. , Clarkson K. , Rowe B.H.
Published: May 2018

Introduction: Emergency Department (ED) Transition Coordinators (TC) have been introduced to many EDs. In Alberta, the EDTC role was designed to evaluate the home needs of senior patients (75 years of age) to enable safe return home after an ED visit, thereby mitigating admissions and return ED visits. The effectiveness of this role at achieving its objectives has received limited evaluation. Methods: TCs assess all ED patients 75 years old, and physicians request TC assessment for patients <75 years. The TC assessment includes completing a Transitional Assessment Referral (TAR) form that collects information on comorbidities, living arrangements, connections to community and homecare services, independence in activities of daily living (ADLs), and referrals, and disposition. Trained research staff extracted data from consecutive TARs for patients presenting during April 2017 into a REDCap database. The proportions of patients seen by TCs who were admitted, had an unplanned return to the ED within the study period, or received a new homecare referral were assessed. Categorical variables are reported as proportions; continuous variables are reported as mean and standard deviation (SD) or median and interquartile range (IQR), as appropriate. Results: In April 2017, there were 9849 visits to the ED; of these, TCs assessed 478 patients during 500 visits. The mean age was 82 (SD=11.2) and 41% were male; 22 patients presented twice during April 2017. Patients had a median of 2 (IQR: 1, 5) co-morbidities and 40 (8%) patients reported falls in the past 90 days (median=1; IQR: 1, 2). Overall, 144 (29%) patients lived in a care facility, while 204 (41%) lived at home; residence was unclear or not documented for 152 (30%). Patients reported being independent in a median of 9/14 (IQR: 3, 13) ADLs. An existing homecare connection or receipt of homecare services was documented for 185 patients (37%). Finally, 59 (12%) visits included a new or updated homecare referral, while 200 (33%) ED visits ended in admission. Conclusion: Elderly patients seen in the ED assessed by EDTCs are complex, and despite being well connected, they frequently need hospitalization. In a small proportion of cases, additional or new home care resources are required prior to ED discharge; however, few patients returned to the same ED during the one month study period. Given the high proportion of patients assessed, further evaluation of outcomes is warranted.
P057: A systematic review of the efficacy of opioid analgesics for the management of acute pain in older adults in the emergency department
Authors: Gravel J. , deVries M. , Horn D. , McLeod S. , Varner C.
Published: May 2018

Introduction: Emergency department (ED) providers are frequently challenged with how best to treat acute pain in older patients, specifically when non-opioid analgesics are insufficient or contraindicated. Studies have documented older patients presenting to the ED with painful conditions are less likely to receive pain medications than younger patients, and this inadequate pain control has been associated with increased risk of delirium and longer hospital stays. As there are no guidelines informing best practice of analgesia in the older adult population, emergency physicians often report uncertainty regarding the ideal choice of opioid analgesic. The objective of this study was to compare the efficacy of opioid analgesics for acute pain in older adults (70 years) in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing the efficacy of 2 or more opioid analgesics for acute pain in older patients (70 years) in ambulatory settings (i.e., EDs, clinics) were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Results: After screening titles and abstracts of 1297 citations, the full-texts of 63 studies were reviewed, and 1 study met the inclusion criteria. This study allocated patients to receive either single dose of 0.0075-mg/kg IV hydromorphone versus 0.05-mg IV morphine and found no clinical or statistical difference between the two treatments in older adults presenting to an urban academic ED with acute, severe pain. Conclusion: The lack of published research in this area demonstrates a significant gap in the existing knowledge of the comparative efficacy of opioid analgesics in this growing patient population and that well-designed RCTs are urgently needed.
P068: Predictors of admission in unscheduled return visits to the emergency department
Authors: Hayward J. , Hagtvedt R. , Ma W. , Vester M. , Gauri A. , Holroyd B. R.
Published: May 2018

Introduction: The 72-hr unscheduled return visit (URV) of an emergency department (ED) patient is often used as a key performance indicator in Emergency Medicine. Patients with unscheduled return visits and admission to hospital (URVA) may represent a distinct subgroup of URVs compared to unscheduled return visits with no admission (URVNA). Methods: A retrospective cohort study of all 72-hr URVs in adults across nine EDs in the Edmonton Zone (EZ) over a one-year period (Jan 1 2015 Dec 31 2015) was performed using ED information system data. URVA and URVNA populations were compared and a multivariable analysis identified predictors of URVA. Results: Analysis of 40,870 total URV records, including 3,363 URVAs, revealed predictors of URVA on the index visit including older age (>65 yrs, OR 3.6), fewer annual ED visits (<4 visits, OR 2.0), higher disease acuity (CTAS 2, OR 2.6), gastrointestinal presenting complaint (OR 2.2), presenting to a large referral hospital (OR 1.4), and more hours spent in the ED (>12 hours, OR 2.0). A decrease in CTAS score (increase in disease acuity) upon return visit was also a risk factor (-1 CTAS level, OR 2.6). ED crowding at the index visit, as indicated by occupancy level, was not a predictor. Conclusion: We demonstrate that URVA patients comprise a distinct subgroup of 72-hr URVs across an entire health region. Risk factors for URVA are present at the index visit suggesting that patients at high risk for URVA may be identifiable prior to admission.
P073: The GridlockED board game: using serious games for medical education
Authors: Huang S. Y. , Sneath P. , Tsoy D. , Rempel J. , Mercuri M. , Pardhan A. , Chan T. M.
Published: May 2018

Introduction: The management of patient flow in the emergency department (ED) is crucial for the practice of emergency medicine (EM). However, this skill is difficult to teach didactically and is learned implicitly in the latter half of residency training. To help expedite the learning process, we developed the GridlockED board game as an educational tool to simulate ED patient flow. By having junior medical trainees play this game, we believe that they will develop a greater understanding of patient flow and resource management in the ED. Additionally, since GridlockED is a cooperative game, players may also benefit by improving their communication and teamwork skills. Methods: GridlockED was developed over twenty months of iterative gameplay and review. Feedback from attending emergency physicians, residents, and medical students was integrated into the game through a Plan-Do-Study-Act (PDSA) model. Emergency medicine nurses, physicians and residents at McMaster University were recruited to play GridlockED. Each player completed a pre-survey to collect demographic data and to assess their prior experience with playing board games. All play sessions were recorded for data collection purposes. Following each game session, a member of the research team conducted an exit interview with the players to gather information about their play experience and the educational value of the game. A post-survey was also sent to each participant for further feedback. Results: Eighteen gameplay sessions were conducted from June to August 2017. A total of thirty-two participants played the game (13 emergency physicians, 15 residents, and four nurses). Overall responses to the post-gameplay survey showed that players endorsed GridlockED as a useful potential teaching tool (75%, n=24/32) and the majority felt that it had the potential to improve patient flow in the ED (56%, n=18/32). Most participants found that the game was easy to play (91%, n=27/29), and that the instructions were clear (87.5%, n=28/32). Respondents also felt that the game reflected real life scenarios (56%, n=18) and that cases reflected the types of patients that they saw in the ED (78%, n=25). Conclusion: Our results have shown an overall positive response to GridlockED, with most participants supporting it as both an engaging board game and potential teaching tool. We believe that future studies with larger sample sizes and medical students will further validate the use of serious games in medical education.
P077: The health inequalities among foreign patients visiting the emergency room with injury: a nationwide population-based study in South Korea, 2013-2015
Authors: Jung S. , Lim H. , Kwon J. , Kim N. , Seo D.
Published: May 2018

Introduction: Foreign patients often do not receive appropriate treatment in the emergency room as compared to locals. This is due to various causes such as language, insurance, and cultural differences. The purpose of this study was to investigate whether there is a wide range of health inequalities among foreigners who visited the emergency room with injury and to find out what causes it. Methods: We analyzed clinical data from the National Emergency Department Information System(NEDIS) database, which visited the emergency room from January 1, 2013 to December 31, 2015, in all age groups. Foreigners are classified based on the personal information described in the NEDIS. We analyzed the number of injuries, serious cases(death, operation, ICU admission), length of stay in ER, and transfer ratio. Results: A total of 4,464,603 cases of injured patients were included, of whom 67,683 were foreign patients. The incidence rate per 100,000 people per year was 2960.5 from locals and 1659.8 from foreigners. Serious outcomes were higher for foreigners than for locals(31.0% versus 23.2%, p<0.001). There was a further difference in the rural region. Length of stay was longer for foreigners(72 versus 69 minutes, median, p<0.001). The transfer rate was also higher for foreigners(1.9% versus 1.6%, p<0.001). Daegu had the highest ratio of foreigners’ injury compared to locals(ratio=0.998). Jeonnam(0.073) was the highest serious outcome rate in Korea, and Jeonbuk(0.070) was the second. The area with the longest length of stay in the Emergency department was the median 139 minutes for locals and 153 minutes for foreigners in Daegu. The more patients per day, the shorter the time spent in the emergency rooms(Spearman correlation coefficient=-0.388). This phenomenon was more prominent in locals(-0.624 versus -0.175). Multivariable logistic regression was used as a dependent variable for the serious outcomes of foreign patients. The foreign patients(OR=1.413, p<0.001), intention, no insurance, age, sex, urban area, low blood pressure, decreased consciousness, transfer, acuity, and length of stay were statistically significant. Conclusion: This study showed that there is a health inequality for foreigners who came to the emergency room due to injury in Korea. Also, serious outcomes from injury in foreigners have been shown to be related to various causes including factors of the foreigner.
P081: ICD-10 coding of free text diagnoses is not reliable for the diagnosis of PE in Calgary zone emergency department patients
Authors: Koger K. , Andruchow J. E. , McRae A. D. , Wang D. , Innes G. , Lang E. S.
Published: May 2018

Introduction: Administrative data are attractive for research, policy and quality improvement initiatives as large amounts of data can often be obtained quickly and at low cost. Unfortunately, administrative data often have significant limitations owing to how they were collected and coded. In many cases, free text, often hand written, diagnoses provided by physicians are converted into ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) codes by trained nosologists for administrative purposes. However, because of the large data sets often obtained from administrative sources, it is difficult to verify the accuracy of the data, which may lead researchers to misleading or false conclusions. The objective of this study was to evaluate the accuracy of ICD-10 codes for the diagnosis of pulmonary embolism (PE) in emergency department (ED) patients. Methods: As part of a larger study examining the effectiveness of a clinical decision support intervention on CT utilization and diagnostic yield for ED patients with suspected PE, all patients with an ICD-10 code corresponding to PE (126.0 and 126.9) on ED discharge were obtained from four adult urban EDs and one urgent care center from August 2016 to March 2017. PE diagnosis was confirmed by reviewing electronic medical records and imaging reports for all patients. Discrepancies between coded ICD-10 diagnoses and actual imaging findings were quantified. This study was REB approved. Results: Of 584 ED patients with ICD-10 codes identifying PE as a discharge diagnosis, 535 had imaging that could be reviewed. Of these, 225 (42.1%) did not have clinical diagnoses of PE, and thus were incorrectly coded, resulting in false positive ICD-10 codes. Common coding errors included physician free text diagnoses of rule out PE or query PE being coded as positive for PE. Conclusion: Administrative data are subject to errors in coding. In this study ICD-10 codes were not reliable for the diagnosis of PE, with 42.1% of PE diagnoses being false positives. Similar coding errors are likely for other diagnoses that require waits for confirmatory imaging (e.g. appendicitis). Nosologist coding of physician free text diagnoses is challenging and prone to errors. Consequently, validation of ICD-10 coding prior to analysis of administrative datasets is crucial for meaningful results.
P092: Combatting sedentary lifestyles; can exercise prescriptions in the emergency department lead to a behavioural change in patients?
Authors: Lewis D. , Leech-Porter K. , Milne F. , Fraser J. , Hull S. , Atkinson P.
Published: May 2018

Introduction: Patients with chronic diseases are known to benefit from exercise. Such patients often visit the emergency department (ED). There are few studies examining prescribing exercise in the ED. We wished to study if exercise prescription in the ED is feasible and effective. Methods: In this pilot prospective block randomized trial, patients in the control group received routine care, whereas the intervention group received a combined written and verbal prescription for moderate exercise (150 minutes/week). Both groups were followed up by phone at 2 months. The primary outcome was achieving 150 min of exercise per week. Secondary outcomes included change in exercise, and differences in reported median weekly exercise. Comparisons were made by Mann-Whitney and Fishers tests (GraphPad). Results: Follow-up was completed for 22 patients (11 Control; 11 Intervention). Baseline reported median (with IQR) weekly exercise was similar between groups; Control 0(0-0)min; Intervention 0(0-45)min. There was no difference between groups for the primary outcome of 150 min/week at 2 months (Control 3/11; Intervention 4/11, RR 1.33 (95%CI 0.38-4.6;p=1.0). There was a significant increase in median exercise from baseline in both groups, but no difference between the groups (Control 75(10-225)min; Intervention 120(52.5-150)min;NS). 3 control patients actually received exercise prescription as part of routine care. A post-hoc comparison of patients receiving intervention vs. no intervention, revealed an increase in patients meeting the primary target of 150min/week (No intervention 0/8; Intervention 7/14, RR 2.0 (95%CI 1.2-3.4);p=0.023). Conclusion: Recruitment was feasible, however our study was underpowered to quantify an estimated effect size. As a significant proportion of the control group received the intervention (as part of standard care), any potential measurable effect was diluted. The improvement seen in patients receiving intervention and the increase in reported exercise in both groups (possible Hawthorne effect) suggests that exercise prescription for ED patients may be beneficial.
P098: Solid organ donation from the emergency department - a systematic review
Authors: McCallum J. , Ellis B. , Stiell I. G.
Published: May 2018

Introduction: There is a significant gap between the number of organ donors and people awaiting an organ transplant; therefore it is essential that all potential donors are identified. Given the nature of Emergency Medicine it is a potential source of organ donors. The purpose of this study is to determine what percent of successful donors come from the Emergency Department (ED) and whether there are any missed potential donors. Methods: Electronic searches of EMBASE, MEDLINE, and CINAHL were performed July 7, 2017 using PRISMA guidelines. Primary literature in human adults were included if they described identification of patients in the ED who went on to become successful solid organ donors, or described missed potential donors in the ED. Data on the total population of actual or missed donors was required to allow calculation of a percentage. Studies describing non-solid organ donation, consent, ethics, survey of attitudes, teaching curricula, procurement techniques, donation outside the ED, and recipient factors were excluded. 2 authors independently screened articles for inclusion and discrepancies were resolved through consensus. Quality was assessed using STROBE for observational studies. Heterogeneity of patient populations precluded pooling of the data to conduct a meta-analysis. Results: 1058 articles were identified, 17 duplicates were removed, 800 articles were excluded based on title and abstract, and 217 full text articles were excluded, yielding 24 articles for the systematic review. For neurologic determination of death (NDD), ED patients comprised 4 44% of successful donors. ED death reviews revealed 0 84% of patients dying in the ED are missed as potential donors and hospital-wide death reviews revealed 13 80.9% of missed donors die in the ED. For donation after cardiac death (DCD), 4 20% of successful donors came from the ED and studies investigating potential donors suggest 2 36% of patients dying the in the ED could be potential DCD donors. The most common population of successful DCD organ donors was in traumatic cardiopulmonary arrest (TCPA), with 3.6 8.9% of TCPA patients presenting to the ED becoming successful donors. Conclusion: Patients dying in the Emergency Department are a significant source of both successful organ donors and missed potential donors. Emergency physicians should be familiar with their local organ donation protocol to ensure potential organ donors are not missed.
P100: Exploring First Nations members emergency department experiences and concerns through participatory research methods
Authors: McLane P. , Jagodzinsky D. , Bill L. , Barnabe C. , Holroyd B. R. , Phillips A. , Louis E. , Saddleback B. , Rittenbach K. , Bird A. , Eshkakogan N. , Healy B.
Published: May 2018

Introduction: Emergency Departments (EDs) are frequently the first point of entry to access health services for First Nation (FN) members. In Alberta, FN members visit EDs at almost double the rate of non-FN persons. Furthermore, preliminary evidence demonstrates differences in ED experience for FN members as compared to the general population. The Alberta First Nations Information Governance Centre, Maskwacis Health Services, Yellowhead Tribal Council, Treaty 8 First Nations of Alberta, and Alberta Health Services are working together to research FN members ED experiences and concerns. Methods: This is participatory research guided by a two-eyed seeing approach that acknowledges the equal value of both Western and Indigenous worldviews. FN and non-FN leaders researchers are full partners in the development of the research project. Six sharing circles will be held in February 2018 across Alberta, with Elders, FN patients, FN and non-FN clinicians and FN and non-FN administrators. Sharing circles are similar to focus groups, but emphasize everyone having a turn to speak and demonstrating respect among participants in accordance with FN protocols. Elders will select the questions for discussion based on topics that arose in initial team meetings. Sharing circle discussions will be audio recorded and transcribed. Analysts will include both Western and Indigenous worldview researchers, who will collaboratively interpret findings. Elders will review, discuss, contextualize and expand upon study findings. The research is also guided by FN principles of Ownership, Control, Access, and Possession of FN information. It is through these principles that First Nation research projects can truly be classified as FN lead and driven. Results: Based on initial team meeting discussions, results of sharing circles are expected to provide insights on issues such as: healing, patient-provider communication (verbal and non-verbal), shared decision making, respect for patient preferences, experiences leading to trust or distrust, understandings of wait times and triage, times when multiple (repeat) ED presentations occur, distances travelled for care, choosing specific EDs when seeking care, impacts of stereotypes about FN patients, and racism and reconciliation. Conclusion: Understanding FN ED experience and bringing FN perspectives to Western conceptions of the goals and provision of ED care are important steps toward reconciliation.
P103: Performance characteristics of the modified Sgarbossa criteria for diagnosis of acute coronary occlusion in emergency department patients with ventricular paced rhythm and symptoms of acute coronary syndrome
Authors: Mitchell G. J. , Dodd K. , Zvosec D. L. , Chen E. , Hart M. A. , Marshall J. , Smith A. A. , Suna J. , Cullen L. , Smith S. W.
Published: May 2018

Introduction: The ECG diagnosis of acute coronary occlusion (ACO) in the setting of ventricular paced rhythm (VPR) is purported to be impossible. However, VPR has a similar ECG morphology to LBBB. The validated Smith-modified Sgarbossa criteria (MSC) have high sensitivity (Sens) and specificity (Spec) for ACO in LBBB. MSC consist of 1 of the following in 1 lead: concordant ST Elevation (STE) 1 mm, concordant ST depression 1 mm in V1-V3, or ST/S ratio <−0.25 (in leads with 1 mm STE). We hypothesized that the MSC will have higher Sens for diagnosis of ACO in VPR when compared to the original Sgarbossa criteria. We report preliminary findings of the Paced Electrocardiogram Requiring Fast Emergency Coronary Therapy (PERFECT) study Methods: The PERFECT study is a retrospective, multicenter, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms suggestive of acute coronary syndrome (e.g. chest pain or shortness of breath). Data from four sites are presented. Acute myocardial infarction (AMI) was defined by the Third Universal Definition of AMI. A blinded cardiologist adjudicated ACO, defined as thrombolysis in myocardial infarction score 0 or 1 on coronary angiography; a pre-defined subgroup of ACO patients with peak cardiac troponin (cTn) >100 times the 99% upper reference limit (URL) of the cTn assay was also analyzed. Another blinded physician measured all ECGs. Statistics were by Mann Whitney U, Chi-square, and McNemars test. Results: The ACO and No-AMI groups consisted of 15 and 79 encounters, respectively. For the ACO and No-AMI groups, median age was 78 [IQR 72-82] vs. 70 [61-75] and 13 (86%) vs. 48 (61%) patients were male. The median peak cTn ratio (cTn/URL) was 260 [33-663] and 0.5 [0-1.3] for ACO vs. no-AMI. The Sens and Spec for the MSC and the original Sgarbossa criteria were 67% (95%CI 39-87) vs. 46% (22-72; p=0.25) and 99% (92-100) vs. 99% (92-100; p=0.5). In pre-defined subgroup analysis of ACO patients with peak cTn >100 times the URL (n=10), the Sens was 90% (54-100) for the MSC vs. 60% (27- 86) for original Sgarbossa criteria (p=0.25). Conclusion: ACO in VPR is an uncommon condition. The MSC showed good Sens for diagnosis of ACO in the presence of VPR, especially among patients with high peak cTn, and Spec was excellent. These methods and results are consistent with studies that have used the MSC to diagnose ACO in LBBB.
P112: FLO on flow: front line ownership of emergency department, hospital, and health system patient flow a novel approach to ED overcrowding (Part 1)
Authors: Petrie D. A. , Ackroyd S. , Comber S. , Mumford K.
Published: May 2018

Introduction: Hospital access block, often called Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving Health Care system. The multiple, dynamic, and inter-dependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems analysis and approach. One technique described in similar contexts is Front Line Ownership (FLO) based on the theoretical framework of positive deviance. The aim of this study is to discover where pragmatic bottom-up insights and adaptive work-arounds can be elicited, described, iterated, and potentially implemented at a broader scale to catalyze systems change, in service of improving patient flow. Methods: This is a qualitative study which identified, convened, and surveyed stakeholders representing three components of the system. Purposive sampling was used to gather a full range of perspectives from three groups: 1) patients and or families, 2) front-line providers, and 3) management/leaders. Interviews were recorded and transcribed by a third party, then each transcription was coded independently by two investigators (at least one of which was the PI). Informed consent was obtained from all participants and each was offered the opportunity to review the transcription to ensure accuracy. A framework analysis was used to synthesize, reflect upon, and interpret the data from multiple perspectives using a structured, iterative approach. Results: In part 1 of this study, three broad over-lapping themes emerged from the analysis as being areas of opportunity for reducing hospital access block. They are: 1. Boundary Conditions (the historical, organizational cultural, psychological, economic, and other contexts influencing system performance), 2. Systems Integration (how well the parts interface with each other relate to the whole), and 3. Operations management (the more technical aspects of patient flow). When these three broad themes are cross-analyzed with a more conventional input-throughput-output approach, previously under-emphasized avenues for improvement may become apparent. Conclusion: A front-line ownership analysis of ED overcrowding is feasible. There are adaptive behaviors by some front-line individuals at each “level” of perspective that have been identified and could be modified and implemented locally to improve patient flow in the ED (and the rest of the health system).
P113: A systematic review and meta-analysis of tourniquet devices for speed of application, successful hemostasis and patient tolerance
Authors: Picard C. , Douma M. J.
Published: May 2018

Introduction: Tourniquets are a mainstay of hemorrhage management. However, there is insufficient evidence to guide device sselection. This review analyses the literature on tourniquets, for the following outcomes: lower-extremity arterial hemostasis, application speed, and pain. Methods: Studies were limited to English. Non-human studies, case series, and intra-operative applications were excluded. A systematic review of MEDLINE, PubMed, Google Scholar, and the Cochrane Database from 1992 to Dec 2017 was performed. Article citations were also assessed. Results: Twenty-one studies met criteria, testing 28 tourniquet devices. The most popular devices for arterial hemostasis were the Combat Application Tourniquet (C-A-T) (662 applications), Special Operations Forces Tactical Tourniquet (SOFTT) (307 applications), blood pressure cuff (80 applications), rubber tubing (58 applications) and the Emergency Medical Tourniquet (EMT) (52 applications). The blood pressure cuff achieved the highest (weighted averages) rate of 99% (95% CI 93 to 100) based on four studies of 80 applications. Followed by the EMT which achieved 83% (95% CI 72 to 93), based on three studies of 52 applications (p<0.01). The fastest device to apply, taking 17 seconds (95% CI 11 to 23), was surgical tubing, based on two studies totalling 30 applications. The next fastest was the blood pressure cuff, requiring 20 seconds (95% CI 18 to 22), based on two studies totaling 58 applications (though there was no statistical difference in application time, p=0.08). Tolerance could not be analyzed, due to heterogeneity of outcome measures. Conclusion: This is the first meta-analysis of tourniquet outcomes. The literature lacks a standard approach to device application. The quality of evidence is of very low due to the small sample sizes, lack of blinding, selective outcome reporting and result inconsistency. Common medical equipment appear to outperform commercial tourniquets for arterial hemostasis and speed of application; however, they are some of the least studied devices.
P121: Derivation of a clinical decision tool for predicting adverse outcomes among emergency department patients with lower gastrointestinal bleeding
Authors: Ramaekers R. , Leafloor C. , Perry J. J. , Thiruganasambandamoorthy V.
Published: May 2018

Introduction: Lower gastrointestinal bleeding (LGIB) can result in serious adverse events, including recurrent bleeding, need for intervention and death. Endoscopy is important in the management of LGIB, however gastroenterologists have limited resources to safe endoscopy. Risk stratification of LGIB patients can aid physicians in disposition decisions. Objective: to develop a clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day serious adverse events. Methods: We conducted a health records review and included 372 adult ED patients who presented with an acute LGIB. The outcome was a 30-day composite outcome consisting of all-cause death, recurrent LGIB, need for intervention to control the bleed and ICU admission. A second researcher confirmed data-collection of 10% of the data and we calculated a -value for inter-rater reliability. We analyzed the data using stepwise backwards selection and SELECTION=SCORE option and calculated the diagnostic accuracy of the final model. Results: Age 75 years, hemoglobin 100 g/L, INR 2.0, a bloody stool in the ED and a past medical history of colorectal polyps were significant predictors in the multivariable regression analysis. The AUC was 0.83 (95% CI 0.77-0.89), sensitivity 0.96 (0.90-1.00), specificity 0.53 (0.48-0.59), and negative likelihood ratio 0.08 (0.02-0.30) for a cut-off score of 1. Conclusion: This model showed good ability to identify LGIB patients at low risk for adverse events as evidenced by the high AUC, sensitivity and negative likelihood ratio. Future, large prospective studies should be done to confirm the data, after which it should be validated and implemented.