bluuebunny/crossref_metadata_2025 huggingface dataset:
P018: Blocked practice outperforms random practice for learning resuscitative transesophageal echocardiography: a randomized controlled trial
Authors: Chenkin J. , Brydges R. , Jelic T. , Hockmann E.
Published: May 2018

Introduction: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application, however the optimal teaching methods have not been determined. Previous studies have demonstrated that random practice (RP), which increases the variability of training, may improve learning of procedural skills compared with blocked practice (BP). We compared RP and BP for teaching a resuscitative TEE protocol to emergency medicine residents using a simulator. Methods: We recruited emergency medicine residents with no prior TEE experience from a university-affiliated hospital. Participants completed a questionnaire and baseline skill assessment on a simulator, then were randomized to one of two groups. The BP group completed 10 repetitions of a fixed 5-view TEE sequence with instructor feedback, while the RP group completed 10 different random 5-view TEE sequences with feedback. Participants completed a simulation-based performance assessment immediately, and a transfer test consisting of a simulated patient encounter 1-2 weeks after training. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. Our primary outcome was the percentage of successful views on the transfer test, and secondary outcomes included participants confidence level, image quality, percentage of correct diagnoses, and efficiency of movement. We compared all scores using two-tailed, independent samples t-tests. Results: 22 participants completed the study (11 in the RP group, 11 in the BP group). There were no significant baseline differences between the groups. The BP group had a higher rate of successful views compared with the RP group on the transfer test (92.7% vs 80.9%, p=0.02). While not statistically significant, the BP group had higher image quality on a 5-point scale (3.2 vs 2.9, p=0.09), and fewer probe accelerations (297 vs 403, p=0.09). The groups did not differ in rate of correct diagnoses (77.3% vs 72.7%, p=0.73), confidence level on a 10-point scale (6.2 vs 6.2, p=1.0), or scan time (173 vs 199 seconds, p=0.28). Conclusion: Emergency medicine residents randomized to BP had a higher success rate on a transfer test, compared to RP when learning resuscitative TEE using a simulator. We consider this pilot work that can inform future studies in both simulation and real clinical settings.
P020: Post-return of spontaneous circulation care and outcomes a single centre experience
Authors: Clemente M. D. , Woolfrey K. , Van Aarsen K. , Columbus M.
Published: May 2018

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. In 2015, the American Heart Association release updated guidelines dictating best practices in post-return of spontaneous circulation (ROSC) care, advocating for more liberal utilization of emergent coronary angiography. We sought to determine if the post-ROSC care at our centre during our study period adhered to the previously published (2010) guidelines. Methods: We performed a retrospective analysis (Sept. 2011 - June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Key variables included rates of post-ROSC emergent angiography, survival to hospital discharge and survival to hospital discharge with favourable neurologic outcome (modified Rankin score 2). Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. Of those who achieved sustained ROSC, median age was 65 years (IQR=21.75), 66.8% were male. ECG interpretation data was available on 214 patients, of whom 56 had definite STEMI, and 135 had definite absence of STEMI. 37/56 (66.1%) definite STEMI patients received coronary angiography within 24 hours of presentation, as per AHA guidelines. 58/262 (22.1%) post-ROSC patients overall received coronary angiography within 24 hours of presentation to the ED. Of those 58 patients who received emergent angiography, 38 (65.5%) underwent percutaneous coronary intervention (PCI). No patients received fibrinolysis. Of post-ROSC patients who received emergent coronary angiography, 40/58 (69.0%) survived to hospital discharge and 37/58 (63.8%) survived with good neurologic outcome. In comparison, 55/204 (27.0%) who did not receive emergent angiography survived to hospital discharge and 18.8% survived with good neurologic outcome. Conclusion: Only 22.1% of patients with OHCA, and only 66.1% with ECG-proven STEMI underwent emergent coronary angiography post-ROSC. Further investigation into causes for delay or the withholding of emergent angiography is necessary.
P021: Outcomes of out of hospital cardiac arrest in London, Ontario
Authors: Clemente M. D. , Woolfrey K. , Van Aarsen K. , Columbus M.
Published: May 2018

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. We sought to determine if outcomes from out of hospital cardiac arrest (OHCA) at our centre were consistent with recently published North American outcomes data from the Resuscitation Outcomes Consortium (ROC). Methods: We performed a retrospective analysis (Sept 2011 June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, in-hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. 92 (35.1%) were receiving ongoing CPR at the time of their presentation to the ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. A total of 95 patients survived to hospital discharge (36.3% of patients who achieved sustained ROSC, 17.1% of those who were transported to the ED, and 10.4% of the all OHCA). Of those who survived to hospital discharge who had neurologic outcome data, 90.5% had a modified Rankin score of 2. Initial presenting rhythm with EMS was ventricular fibrillation or pulseless ventricular tachycardia in 233 patients. Of these, 212 (91.0%) were transported to the ED, 134 (57.5%) achieved sustained ROSC, and 71 (30.5%) survived to hospital discharge. 54/60 (90.0%) of those with a documented neurologic exam had a favourable neurologic outcome. Initial presenting rhythm with EMS was PEA or asystole in 636 patients. Of these, 320 (50.3%) were transported to the ED, 115 (18.1%) achieved sustained ROSC, and 17 (2.7%) survived to hospital discharge. 9/10 (90%) of those with a documented neurologic exam had a favourable neurologic outcome. 358 of the arrests were witnessed. Of these, 274 (76.5%) were transported to the ED, 150 (41.9%) achieved sustained ROSC, and 51 (15.9%) survived to hospital discharge. 47/53 (88.7%) of those with a documented neurologic exam had a favourable neurologic outcome. Conclusion: Outcomes from out of hospital cardiac arrest in London, Ontario are comparable to other sites across North America.
P026: Opioid use and dependence three months after an emergency department visit for acute pain
Authors: Daoust R. , Paquet J. , Morris J. , Cournoyer A. , Piette E. , Lessard J. , Castonguay V. , Gosselin S. , Chauny J.
Published: May 2018

Introduction: Most studies evaluating prescription opioid dependence or misuse are retrospective and are based on prescription filling rates from pharmaceutical databases. These studies cannot evaluate if opioids are really consumed nor differentiate if used for a new pain, chronic pain, or for misuse/dependence. The aim of this study was to assess the opioid consumption in emergency department (ED) patients three months after discharge with an opioid prescription. Methods: This prospective cohort study was conducted in the ED of a tertiary care centre with a convenience sample of patients aged 18 years and older, recruited 24/7, who consulted and were discharged for an acute pain condition ( 2 weeks). We excluded patients who: did not speak French or English, were using opioid medication prior to their ED visit, with an ED stay > 48 hours, or suffering from cancer or chronic pain. Three months post-ED visit, participants were contacted by phone for a structured interview on their past two-week opioid use, their reasons for consuming them, and also answered the Rapid Opioid Dependence Screen (RODS) questionnaire. Results: In the 524 participants interviewed at three months (mean age ± SD: 51±16 years, 47% women), 44 (8.4%) patients consumed opioids in the previous two weeks. Among those, 72% consumed opioids for their initial pain, 19% for a new unrelated pain, and 9% for another reason. In this entire cohort, only five patients (1%) tested positive to opioid dependence from the RODS test. The low dependence incidence could be affected by a social desirability bias. Conclusion: This study suggests that opioid use at 3-month, for patients initially treated for acute pain, is associated with opioid dependency in 1% or possible misuse in only 9%. Additional prospective studies using multiple methods to measure opioids consumption, misuse, and dependence are needed.
P027: A descriptive needs-based assessment of paramedic continuing education
Authors: Davis M. , Leggatt L. , Van Aarsen K. , Romano S.
Published: May 2018

Introduction: Objective: To identify self-perceived knowledge deficits of paramedics, barriers to training and desired methods of self-directed continuing education. Methods: A written 58 question survey was delivered to all 1262 paramedics under the jurisdiction of a single base-hospital in Ontario, Canada. Respondents were asked to select deficit, no deficit or not applicable from a 37-point, anatomic systems-based list. They were then asked to identify from a 15-point list which educational modalities they would choose to address any knowledge deficits. Finally, they were asked which factors they took into consideration when choosing their self-directed continuing education. Results: Seven hundred forty-six of 1262 paramedics (59.11%) completed the surveys. Of these respondents, 82 (10.99%) were advanced care paramedics, while 664 (89.01%) were primary care paramedics. Of the 645 who responded with their primary geographical setting: 136 (21.09%) listed a primary urban practice, 126 (19.53%) listed a primary rural practice and 287 (44.50%) reported a split urban and rural practice. The most common perceived deficits (respondent number, percentage); were electrolyte disturbance (418, 56.03%), neonatal resuscitation (386, 51.74%), pediatric respiratory disorder (381, 51.07%), arrhythmia (377, 50.53%), and pediatric cardiac arrest (317, 42.49%). The top 5 educational opportunities they were most likely to choose included online module (464, 62.20%), in-class lecture (423, 56.70%), web-based review (403, 54.02%), webinar (301, 40.35%) and peer consult (237, 31.77%). The top 3 barriers to choosing continuing education were work scheduling (479, 64.21%), location/ease of attending (382, 51.21%), and cost (305, 40.88%). Conclusion: Paramedics in this base hospital system identified pediatric critical care situations, electrolyte abnormalities and cardiac arrhythmia as self-perceived deficits. The most commonly selected educational opportunities included online learning, in-person training and peer consult. These preferred modalities are consistent with the identified barriers of work scheduling, ease of attending and cost. Targeted educational needs based assessments can help ensure that appropriate topics are delivered in a fashion that help overcome identified barriers to self-directed learning.
P029: A descriptive analysis of defibrillation vector change for prehospital refractory ventricular fibrillation
Authors: Davis M. , Schappert A. , Van Aarsen K. , Loosley J. , McLeod S. , Cheskes S.
Published: May 2018

Introduction: Patients in ventricular fibrillation (VF) who do not respond to standard Advanced Cardiac Life Support treatments are deemed to be in refractory VF (rVF). The ideal prehospital treatment for patients with rVF remains unknown. Double sequential external defibrillation (DSED) has been proposed as a viable option for patients in rVF. Although the mechanism by which DSED terminates rVF remains unknown, one theory is that the change in defibrillation vector that occurs may contribute. The objective of this study was to describe clinical outcomes for patients presenting in rVF during out-of-hospital cardiac arrest (OOHCA) for those who underwent vector change defibrillation, compared to those who received standard treatment. Methods: This was a retrospective chart review of adult (18 years) patients presenting in rVF during OOHCA over 15 months beginning in March 2016. Patients who underwent vector change defibrillation had a change in pad position (anterior-anterior to anterior-posterior) after 3 or more consecutive shocks. Termination of rVF was defined as the absence of VF after a vector change or standard shock during the next rhythm analysis. Results: There were 372 OOHCA, with 25 (6.7%) patients meeting our definition of rVF. Of these, 16 (64.0%) patients (median age 62 years, 81.3% male) had vector change after a median (IQR) of 3 (3.0-4.0) paramedic defibrillation attempts. Median (IQR) time to vector change defibrillation was 8.8 (7.1-11.1) minutes. Eight (50%) patients had termination of rVF after the first vector change shock, 6 (37.5%) had prehospital return of spontaneous circulation (ROSC) and 5 (31.3%) patients survived to hospital discharge. Of the 9 rVF patients who did not have vector change, median age was 63 years and 88.9% were male. The median (IQR) number of defibrillations within this group was 5 (4.5-7.0). No patients converted after the 4th defibrillation. Prehospital ROSC was achieved in 3 (33.3%) patients and 5 (55.5%) patients were transported while in rVF . Three patients (33.3%) survived to hospital discharge. Conclusion: This is preliminary evidence that vector change defibrillation in patients with rVF may result in VF termination. A randomized controlled trial is warranted to test whether or not vector change has a role in the termination of rVF.
P034: Audit and feedback for emergency physicians - perceptions and opportunities for optimization
Authors: Dowling S. K. , Rivera L. , Wang D. , Lonergan K. , Rich T. , Lang E. S.
Published: May 2018

Introduction: There is a growing interest in providing clinicians with performance reports via audit and feedback (A&F). Despite significant evidence exists to support A&F as a tool for self-reflection and identifying unperceived learning needs, there are many questions that remain such as the optimal content of the A&F reports, the method of dissemination for emergency physicians (EP) and the perceived benefit. The goal of the project was to 1. evaluate EP perceptions regarding satisfaction with A&F reports and its’ ability to stimulate physicians to identify opportunities for practice change and 2. identify areas for optimization of the A&F reports. Methods: EP practicing at any of the four adult hospital sites in Calgary were eligible. We conducted a web survey using a modified Dillman technique eliciting EP perspectives regarding satisfaction, usefulness and suggestions for improvement regarding the A&F reports. Quantitative data were analyzed descriptively and free-text were subjected to thematic analysis. Results: From 2015 onwards, EP could access their clinical performance data via an online dashboard. Despite the online reports being available, few physicians reviewed their reports stating access and perceived lack of utility as a barrier. In October 2016, we began disseminated static performance reports to all EP containing a subset of 10 clinical and operational performance metrics via encrypted e-mail. These static reports provided clinician with their performance with peer comparator data (anonymized), rationale and evidence for A&F, information on how to use the report and how to obtain continuing medical education credits for reviewing the report. Conclusion: Of 177 EP in Calgary, we received 49 completed surveys (response rate 28%). 86% of the respondents were very/satisfied with the report. 88% of EP stated they would take action based on the report including self-reflection (91%) and modifying specific aspects of their practice (63%). Respondents indicated that by receiving static reports, 77% were equally or more likely to visit the online version of the eA&F tool. The vast majority of EP felt that receiving the A&F reports on a semi-annual basis was preferred. Three improvements were made to the eA&F based on survey results: 1) addition of trend over time data, 2) new clinical metrics, and 3) optimization of report layout. We also initiated a separate, real-time 72-hour bounceback electronic notification system based on the feedback. EP value the dissemination of clinical performance indicators both in static report and dashboard format. Eliciting feedback from clinicians allows iterative optimization of eA&F. Based on these results, we plan to continue to provide physicians with A&F reports on a semi-annual basis.
P036: Interim analysis of the impact of the emergency department transformation system on flow metrics
Authors: Dukelow A. , Van Aarsen K. , MacDonald C. , Dagnone V.
Published: May 2018

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two Canadian tertiary care Emergency Departments (ED) between June 2014 to July 2016. The goals were to improve patient care by increasing value and reducing waste. Longer times to physician initial assessment (PIA), ED length of stays (LOS) and times to inpatient beds are associated with increased patient morbidity and potentially mortality. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards and a novel initial assessment process ED access block has limited full implementation of EDST. An interim analysis was conducted to assess impact of interventions implemented to date on flow metrics. Methods: Daily ED visit volumes, boarding at 7am, time to PIA and LOS for non-admitted patients were collected from April 2014 -June 2016. Volume and boarding were compared from first to last quarter using an independent samples median test. Linear regression for each variable versus time was conducted to determine unadjusted relationships. PIA, LOS for non-admitted low acuity (Canadian Triage and Acuity Scale (CTAS) 4,5) and non-admitted high acuity (CTAS 1,2,3) patients were subsequently adjusted for volume and/or boarding to control for these variables using a non-parametric correlation. Results: Overall, median ED boarding decreased at University Hospital (UH) (14.0 vs 6.0, p<0.01) and increased at Victoria Hospital (VH) (17.0 vs 21.0, p<0.01) from first to last quarter. Median ED volume increased significantly at UH from first to last quarter (129.0 vs 142.0, p<0.01) but remained essentially unchanged at VH. 90th percentile LOS for non-admitted low acuity patients significantly decreased at UH (adjusted rs=-0.24, p<0.01) but did not significantly change at VH. For high acuity patients 90th percentile LOS significantly decreased at both hospitals (UH: adjusted rs=-0.23, p<0.01; VH: adjusted rs=-0.21, p<0.01). 90th percentile time to PIA improved slightly but significantly in both EDs (UH: adjusted rs=-0.10, p<0.01; VH: adjusted rs=-0.18, p<0.01). Conclusion: Persistent ED boarding impacted the ability to fully implement the EDST model of care. Partial EDST implementation has resulted in improvement in PIA at both LHSC EDs. At UH where ED boarding decreased, LOS metrics improved significantly even after controlling for boarding.
P037: Training first-responders to administer anaphylaxis publically available epinephrine a randomized study
Authors: Dunfield R. J. , Riley J. , Vaillancourt C. , French J. P. , Fraser J. , Atkinson P.
Published: May 2018

Introduction: Improving public access and training for epinephrine auto-injectors (EAIs) can reduce time to initial treatment in anaphylaxis. Effective use of EAIs by the public requires bystanders to respond in a timely and proficient manner. We wished to examine optimal methods for effective training and skill retention for public use of EAIs. Methods: In this prospective, stratified randomized study, 154 participants at 15 sites receiving installation of public EAIs were randomized to one of three experimental education interventions: A) didactic poster (POS) teaching; B) poster with video teaching (VID), and C) Poster, video, and simulation training (SIM). Participants were tested by participation in a standardized simulated anaphylaxis scenario at 0-months, immediately following training, and again at follow-up at 3 months. Participants responses were videoed and assessed by blinded raters. Patient recorded experience measures (PREMs) assessed participant-patient interaction for every scenario. Data that was non-normally distributed was analyzed using non-parametric testing (Kruskall-Wallis-Rank Sum-Test). Results: Initial analysis showed differences between group baseline characteristics for age and first aid training; with a multivariable analysis providing the effect size of these differences. PREM data and video assessment data were not normally distributed. Analysis of PREM data revealed significantly higher scores in the SIM group at 0-months (median=6.5, IQR=5; p=0.05) and 3-months (median=5, IQR=3; p<0.01), compared to those groups that did not receive SIM. Video assessment performance scores show trends in higher skills and knowledge retention for SIM participants at 3-months; full data analysis will be performed at a later date. Final video assessment analysis will involve a weighted scoring system, using a consensus process, and an inter-rater agreement analysis. Conclusion: Simulation training improves interaction, essential skills, and retention of knowledge in simulated anaphylaxis response with public EAIs compared to non-simulation-based training.
P038: Emergency medicine interest group: evaluation of a student led organization at Memorial University
Authors: Dunne C. , Hansen D. , Parsons M.
Published: May 2018

Introduction: Interest groups have become increasingly popular as students explore potential career paths earlier in their undergraduate experience. Emergency medicine (EM) has grown as a specialty and the match has become quite competitive. Attractive features of EM cited by learners (diversity, procedural skills and flexible schedule) appeal broadly to the undergraduate population. Learners at Memorial University recognized this leadership opportunity and worked with faculty to reach this wide target audience through a streamlined iterative evaluation of their EM Interest Group (EMIG). Methods: The local EMIG was formed in 2010. Yearly, EMIG executive work with outgoing members using prior experiences, contacts and best practices to facilitate handover and progress. From 2015 to present, 305 surveys were collected, giving an 81.9% response rate. 59.7% of respondents were first year students, and 40.3% were second year. The survey consisted of Likert scale and open-response questions. The Likert scale questions yielded favorable responses. 304 students (99.6%) felt presenters were knowledgeable, 301 (98.6%) would recommend the sessions to others and 301 (98.6%) were satisfied they attended. Surprisingly, 133 students (43.6%) said they were not interested in Emergency Medicine, likely attending due to the appeal of session topics and transferrable of EM skills. 232 (76.0%) stated that attendance did increase their interest in EM. Top responses for aspects of EM most interesting to them included: ability to find a work/life balance, ability to work urban or rural, variety of cases seen, and the non-routine shifts. Results: Survey feedback is used to inform refinement of the content, delivery and format of EMIG activities, delivered by EM faculty. Hands-on sessions (eg. suturing & airway management) have been popular. Informational sessions, on specific medical topics (ECG, resuscitation cases) or broader topics (EM streams) have also been very well received. Inclusion of all interested students, particularly large numbers for hands-on sessions, has presented challenges. Beyond current survey results, it will be interesting to consider if EMIG participation translates to learning or behavioral changes relevant to later clinical encounters; a question that will be difficult to quantify. Conclusion: The EM interest group is one of the most active at Memorial University. Survey results indicate that participants enjoy the EMIG session content and the structured iterative approach used by the group has been successful in maintaining an effective student led organization.
P041: Patient perspectives on emergency department use for acute atrial fibrillation: a qualitative study using the theoretical domains framework
Authors: Eagles D. , Cheung W.J. , Lee E. , Tang T. , Stiell I.G.
Published: May 2018

Introduction: Acute atrial fibrillation (AAF) is the most common arrhythmia managed in the Emergency Department (ED). Direct costs of AAF are primarily attributed to ED visits and subsequent admission to hospital. A better understanding of patients attitudes regarding ED attendance is necessary to develop strategies to improve the patient care experience while simultaneously reducing ED presentation and inappropriate hospital admissions. This study aims to describe patient perspectives on ED use for AAF using in-depth qualitative interviews. Methods: An interview template designed to explore why patients attend the ED for AAF was constructed based on the Theoretical Domains Framework, a theory-informed approach that utilizes 14 domains to describe influencers of behavior. We conducted audio-recorded, semi-structured interviews of patients following their presentation to the ED for management of AAF. Interviews were anonymized, transcribed and imported into NVivo for coding and analysis. Two independent reviewers used a direct approach to code participant statements. Discrepancies were resolved by a third party. Belief statements were generated and relevant domains identified based on high frequency scores, conflicting belief statements or evidence of strong influencing beliefs. Results: 12 patient interviews, mean age 63.1 years, 91.7% male, 75.0% recurrent AAF, were completed. Patients stated that they attended the ED because: 1) symptom severity; 2) they were instructed by physicians to attend the ED should their AAF recur; and 3) they were encouraged by family members to attend. Their primary goal was to have relief of their symptoms. There was no expectation of specialist consultation or admission to hospital. Even though most patients stated they were open to managing these episodes independently, they reported that they did not have the knowledge or tools to do so. Conclusion: Patients with AAF present to the ED because of their symptom burden, social influences (physician and family) and lack of other management options. This study demonstrates the need for development of patient self-management strategies which will empower patients in their disease management and may decrease future ED visits.
P043: Standards for change: developing international minimum standards for the care of older people in the emergency department
Authors: Ellis B. , Carpenter C. , Lowthian J. , Mooijaart S. , Nickel C. , Melady D.
Published: May 2018

Introduction: Emergency departments (ED) across Canada acknowledge the need to transform in order to provide high quality care for the increasing proportion of older patients presenting for treatment. Older people are more complex than younger ED users. They have a disproportionately high use of EDs, increased rates of hospitalization, and are more likely to suffer adverse events. The objective of this initiative was to develop minimum standards for the care of older people in the emergency department. Methods: We created a panel of international leaders in geriatrics and emergency medicine to develop a policy framework on minimum standards for care of older people in the ED. We conducted a literature review of international guidelines, frameworks, recommendations, and best practices for the acute care of older people and developed a draft standards document. This preliminary document was circulated to interdisciplinary members of the International Federation of Emergency Medicine (IFEM) geriatric emergency medicine (GEM) group. Following review, the standards were presented to the IFEM clinical practice group. At each step, verbal, written and online feedback were gathered and integrated into the final minimum standards document. Results: Following the developmental process, a series of eight minimum standard statements were created and accepted by IFEM. These standards utilise the IFEM Framework for Quality and Safety in the ED, and are centred on the recognition that older people are a core population of emergency health service users whose care needs are different from those of children and younger adults. They cover key areas, including the overall approach to older patients, the physical environment and equipment, personnel and training, policies and protocols, and strategies for navigating the health-care continuum. Conclusion: These standards aim to improve the evaluation, management and integration of care of older people in the ED in an effort to improve outcomes. The minimum standards represent a first step on which future activities can be built, including the development of specific indicators for each of the minimum standards. The standards are designed to apply across the spectrum of EDs worldwide, and it is hoped that they will act as a catalyst to change.
P050: How aware is safe enough? Situational awareness is higher in safer teams doing simulated emergency airway cases
Authors: French J.P. , Maclean D. , Fraser J. , Benjamin S. , Atkinson P.
Published: May 2018

Introduction: Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about the patient condition, stability, the operational environment and an appropriate clinical course. The Situational Awareness Global Assessment Tool (SAGAT) is a validated tool for measuring situational awareness. The SAGAT tool was measured during a series of standardized high fidelity advanced airway management simulations in multidisciplinary teams in New Brunswick Emergency Departments delivered by two simulation programs Methods: Thirty eight simulated emergency airway cases were performed in situ in Emergency Departments and in learning centers in Southern New Brunswick from September 2015 to October 2017. Eight standardized cases were used whose educational objectives were to develop the optimization of critically ill patients prior to induction, to deliver patient-centered anesthesia and to choose an appropriate airway strategy. Learner profiles collected. Cases were divided into two groups; those that contained critical errors and those that did not based on video assessment. Critical errors were defined as failure of 1) Oxygenation 2) Shock correction 3) Induction dose estimation 4) Choice of airway management paradigm. The SAGAT has a maximum score of 13 and was assessed by research nurses after each case for all participants. SAGAT scores were non-normally distributed, so results were expressed as medians with interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. Results: Results. Of the 38 cases, 14 contained one more critical errors. The median SAGAT score in the group that contained critical errors was 8 +/− 2 (IQR). The median SAGAT Score in the group that contained no critical errors was 11 +/− 2 (IQR). The median scores we significantly different with a p-value of 0.02. Conclusion: In this study in simulated emergency cases, higher SAGAT scores were associated with teams leaders that did not commit safety critical errors. This work is the initial analysis to develop standards for Simulated team performance in Emergency Department teams.
P054: Interventions aimed at improvement in emergency department related transitions in care for adult patients with atrial fibrillation and flutter: a systematic review
Authors: Gilbertson J. , Moghrabi R. , Kirkland S.W. , Tate K. , Sevcik W. , Lam N. , Rowe B.H. , Villa-Roel C.
Published: May 2018

Introduction: Introduction: Transitions in care (TiC) interventions have been proposed to improve the management and outcomes of patients in emergency departments (ED). The objective of this review was to examine the effectiveness of ED-based TiC interventions to improve outcomes for adult patients presenting to an ED with acute atrial fibrillation or flutter (AFF). Methods: Methods: A comprehensive search of eight electronic databases and various grey literature sources was conducted. Comparative studies assessing the effectiveness of interventions to improve TiC for patients presenting to the ED with acute AFF were eligible. Two independent reviewers completed study selection, quality assessment, and data extraction. When applicable, relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity was reported among studies using I-square (I2) statistics. Results: Results: From 744 citations, seven studies were included, consisting of three randomized controlled trials (RCT), three before-after (B/A) studies, and one cohort study. Study quality ranged from unclear to low for the RCTs according to the risk of bias tool, moderate in the BA trials according to the BA quality assessment tool, and high quality of the cohort study according to the Newcastle Ottawa scale. The majority of interventions were set within-ED (n=5), including three clinical pathways/management guidelines and two within-ED observation units. Post-ED interventions (n=2) included patient education and general practitioner referral. Four studies reported a decreased overall hospital length of stay (LoS) for AFF patients undergoing TiC interventions compared to control, ranging from 26.4 to 53 hours; however, incomplete and non-standardized outcome reporting precluded meta-analysis. An increase in conversion to normal sinus rhythm among TiC intervention patients was noted, which may be related to increased utilization of electrical cardioversion among the RCTs (RR=2.16; 95% CI: 1.42, 3.30; I2=%), B/A studies (RR=2.69, 95% CI: 2.17, 3.33), and cohort study (RR=1.39; 95% CI: 1.24, 1.56). Conclusion: Conclusions: Within-ED TiC interventions may reduce hospital LoS and increase use of electrical cardioversion. However, no clear recommendations to implement such interventions in EDs can be generated from this systematic review and more efforts are required to improve TiC for patients with AFF.
P055: An international, interprofessional investigation of the podcast listening habits of emergency clinicians: a METRIQ Study
Authors: Goerzen S.M. , Thoma B. , Horeczko T. , Riddell J. , Chan T.M. , Tagg A. , Roland D. , Alenyo A. , Knight K. , Bruijns S.
Published: May 2018

Introduction: Emergency medicine clinicians (physicians, nurses, paramedics, physician assistants) utilize podcasts for learning. However, their versatility produces variability in the ways they are used (e.g. their speed can be increased or decreased, unrelated activities can be performed simultaneously, or they can be accompanied by active learning methods). This study investigated how and why podcasts are used by an international cohort of clinicians. Methods: An international sample of medical students, residents, physicians, nurses, physician assistants, and paramedics was recruited to complete a survey hosted on FluidSurveys software using social media (Twitter and Facebook), direct contact from our international authorship group, infographics, and a study website (https://METRIQstudy.org/). Participants who indicated interest in the study were sent an email containing the study survey. Reminder emails were sent every 5-10 days a maximum of three times. Results: 462 clinicians expressed interest and 397 completed the survey (86.0% completion rate). Participants hailed from 34 countries (38.8% Canada, 30% United States, 31.2% outside of North America) and a majority (61.9%) were physicians. Approximately half (45.8%) of the participants listened to podcasts weekly. Podcasts were used to learn core material (75.1%), refresh memory (72.3%), or review new literature (75.8%). Most listened on iPhones (61%) and the native Apple App (66.1%). The preferred Android apps were Pocket Casts (22.8%) and Google Play (18.5%). Many listened to podcasts while driving (72.3%). Active learning techniques such as pausing, repeating segments, taking notes, or listening to a podcast more than once were rarely used (1/4 of the time or less) by the majority of participants. Conclusion: This study describes how and why medical education podcasts are used by emergency medicine clinicians and should inform both podcast producers and future research investigating the impact of various listening habits on retention. Further analysis of the data will elucidate differences in listening habits
P056: Non-invasive measurement of the central venous pressure using near-infrared spectroscopy versus point-of-care ultrasound
Authors: Goumeniouk N. , Newbigging J. , McDonnell M. , Sivilotti M.L.A.
Published: May 2018

Introduction: A fundamental hemodynamic parameter, the central venous pressure (CVP) is rarely available in the emergency patient due the delay and risks inherent to central vein cannulation. Recently, two non-invasive strategies have emerged: a) point-of-care ultrasound to supplement traditional inspection the internal jugular waveform ; or b) near-infrared spectroscopy (NIRS) of the external jugular vein. Methods: Five medical students underwent standardized training on both NIRS device (Venus 2000 CVP; Mespere Life Sciences, Waterloo ON) and ultrasound-assisted CVP assessment. During prescheduled, randomly permuted and balanced shifts, a pair of students obtained blinded independent measurements using each device within 10 minutes of each other. High priority subjects likely to have abnormal CVP (e.g. vomiting, dehydrated, heart failure, sepsis) were approached preferentially, followed by a convenience sample of other eligible patients in the emergency department. Secondary outcomes were stopwatch-recorded time from device ready to stable measurement, as well as operator ease, operator confidence and patient discomfort. The blinded treating physician rated each subjects volume status on an ordered scale: depleted, neutral and overloaded. Results: We enrolled 104 patients (median [IQR] age 68 [53, 78] years; 50% male; BMI 27.6 [17.0, 47.7] kg/m2; admission rate 27%) in June-August 2017. Treating physicians classified 17 as volume depleted and 12 overloaded. CVP measurements differed widely between techniques: ultrasound 8 [7, 9] cmH2O (3 cases unobtainable) vs NIRS 12 [8, 17] cmH2O (13 unobtainable). Agreement and correlation between the two devices was extremely low (R2=0.04). While neither technique demonstrated a strong association with the treating physicians estimate of volume status, only the ultrasound values increased monotonically with physician estimate. With regards to secondary outcomes, ultrasound measurements took less time (paired difference 50 seconds [95% CI 7, 93]), and operators were more confident (0.63 [0.02, 1.23] out of 10) and at ease (0.78, [0.13, 1.43]) with ultrasound; patients rated discomfort equally (-0.06 [-0.30, 0.18]). Conclusion: Non-invasive measurement of CVP remains a challenge in the emergency department. The external jugular pressure by NIRS has very high variability and poor agreement with ultrasound-enhanced inspection of the internal jugular, suggesting that this technique is not yet practical for use by non-experts.
P060: Incidence of child and youth presentations to the emergency department for addictions and mental health
Authors: Hair H. , Huebert K. , Bercov M. , Fraser N. , Allen A.
Published: May 2018

Introduction: As reported by the Canadian Institute for Health Information, the rate of child and youth emergency department (ED) visits for mental health complaints increased by 50% between 2007 and 2015. Improving care for these patients has been identified as a major priority of Alberta Health Services As part of a multi-phased approach to improving care, the Emergency and the Addiction and Mental Health Strategic Clinical Networks undertook an analysis of administrative data to define incidence in Alberta and changing trends. Methods: The data analyzed included 5 different clinical information systems encompassing the 17 highest volume hospitals in Alberta, from April 2013 to March 2016. Patient encounters were included if the patient was under 25 years of age at the time of visit, and if the encounter included a CEDIS Presenting Complaint and/or an ICD-10 Primary Diagnosis relating to Addiction and/or Mental Health (AMH). A total of 54,810 patient encounters were included. Data was analyzed using descriptive statistics. Sub-group analysis was undertaken based upon age, presenting complaint, and primary diagnosis. Results: The incidence of children and youth presenting to an ED with an AMH complaint and an AMH primary diagnosis increased 22% and 7%, respectively, from 2013/14 to 2015/16. Admissions of patients were constant throughout this period. The largest increase in ED visits occurred among children aged 7-10, with a 60% increase in visits defined by presenting complaint and a 21% increase in primary diagnosis. The second largest increase was in young adults aged 18-21 with a 26% increase defined by presenting complaint, and a 12% increase in primary diagnosis. Analyzed by age group, the largest increase in primary diagnosis between 2013/14 and 2015/16 was seen in Depression/Suicidal/Self Harm with a 667% increase among ages 0-6, and a 79% increase among ages 7-10. The second highest increase was for Anxiety/Situational Crisis with a 223% increase among ages 0-6, and 74% among children aged 7-10. Conclusion: Within Alberta there has been a substantial increase in the incidence of child and youth visits to the ED for issues of mental health and addictions. It is clear is that these changing trends are placing an increased burden on our healthcare system and necessitate strategic planning to ensure the health and wellness of our patients.
P062: The feasibility of pertussis immunization in a Canadian emergency department
Authors: Hansen D. , Sibley A. K. , MacSwain M. , Morrison H. , Rowswell C.
Published: May 2018

Introduction: Despite clear health benefits, and Public Health Agency of Canada recommendations, vaccination rates among Canadian adults are low. Frequent patient contacts, wait times, and the availability of trained staff make the emergency department (ED) a potential location to target specific populations and administer vaccinations. We evaluated the feasibility of two strategies to administer the Tdap vaccine to adult patients presenting to a single referral ED. Methods: Two immunization strategies and a control group were randomly ordered from one to three. Data collection for group one started on study day one with data collection for groups two and three on study days two and three respectively. This sequence was repeated over 15 consecutive weekdays (Monday-Friday, 0730-1530), evenly assigning each group to 5 different days. On intervention days, adult patients were screened during the triage process for eligibility to receive the Tdap vaccine. An ED based (EDB) strategy offered patients vaccination during that visit. The second strategy offered eligible patients a public health referral (PHR) to receive the vaccine at a later date. On all study days, patient triage times (TT), as well as markers of ED efficiency (number of patient registrations, time to physician, length of stay, left without being seen, number of admissions, number of boarded patients) were recorded. Results: The primary outcome, the proportion of eligible adults immunized, was significantly higher at 66% (n=81) for the EDB strategy (228 screened, 122 eligible), compared with 21% (n=20) for the PHR strategy (217 screened, 94 eligible; x2 (2, n=216)=43.41, p<0.00001). In addition, 10 participants in the PHR group received a second vaccine (Pneumococcal (7), Influenza (2), Human Papillomavirus (1)). Reasons for vaccine ineligibility included having an up-to-date Tdap (EDB n=47 (21%), PHR n=46 (21%)) and being considered in too much distress by the triage nurse (EDB n=26 (11%), PHR n=19 (9%)). Triage time was less for the control group (M=5:55 [mins:secs], SD=2:48) than for the EDB (M=6:47, SD=3:12) and PHR (M=7:25, SD=2:45) strategies. Conclusion: An ED based screening and immunization strategy was highly effective in providing eligible adult patients with the Tdap vaccine. A resulting small increase in triage time was not clinically significant. Further studies are required to generalize these results.
P065: Development and implementation of a postpartum hypertension recognition and management protocol for use in the emergency department
Authors: Hawkins T. , Dowling S. K. , Wang D. , Mahajan A. , Mageau A. , Musto R. , Metcalfe A. , Nerenberg K.
Published: May 2018

Introduction: Hypertensive disorders of pregnancy (HDP), including preeclampsia, can develop or worsen in the early postpartum period, often following discharge from hospital, resulting in severe preventable maternal morbidity and mortality. Due to a lack of routine early out-patient follow-up, many women with postpartum HDP present to the emergency department (ED) with severe hypertension or symptoms of preeclampsia (e.g., headache). In the ED, postpartum HDP can be difficult for clinicians to recognize (due to vague presenting symptom) and manage (due to lower blood pressure targets and concern of medication safety). ED clinicians recognized a need for timely recognition and effective treatments for postpartum HDP in the ED to improve maternal outcomes. As such, as part of a multi-step quality improvement initiative, an interdisciplinary team developed and implemented a postpartum HDP management protocol (consisting of nursing and physician protocols and an electronic order set embedded in the electronic medical record). The aims of this specific project were to assess: 1) the use of this clinical management protocol in the ED; and 2) its impacts on clinical care. Methods: This quality improvement project used electronic medical records to identify: 1) ED visits for postpartum HDP for postpartum women ages 20-50; 2) utilization of the postpartum HDP order set; and 3) clinical care outcomes (consultation and admission). Patient population characteristics and clinical care measures were summarized with descriptive statistics and compared using a before and after design. Changes in the utilization of the protocol were assessed using run charts. Results: 540 women with postpartum HDP were seen in the four Calgary EDs in the 16-month period following protocol implementation compared with 335 women in the preceding 12 months. The protocol was used in 46% of these 540 women, and increased over the 16 month follow-up period. We found an increase in the frequency of consultation of specialists (47% to 52%) and admissions (26% to 29%) amongst these women after protocol implementation. Conclusion: This initial assessment demonstrated good uptake of a postpartum HDP management protocol including referral for consultation and admission to hospital for blood pressure management. Future steps include evaluation of the impacts of this management protocol on important patient outcomes.