bluuebunny/crossref_metadata_2025 huggingface dataset:
P067: Ondansetron and rehydration in pediatric gastroenteritis
Authors: Léa S. , Laurier E. , Vasil M. , Giasson C. , Royer S.
Published: May 2020

Introduction: Gastroenteritis (GE) is one of the most common causes of emergency room visits, especially in pediatrics. The Canadian Paediatric Society and Choosing Wisely have issued high-grade recommendations to physicians working in the Emergency Department. It suggests, trying oral ondansetron followed by oral rehydration before installing venous rehydration in children with GE with adequate hydration or mild to moderate dehydration. This quality of medical care evaluation aims to determine if these recommendations were being applied for children aged 6 months to 12 years, with adequate hydration status or mild to moderate dehydration, who presented to the Chicoutimi emergency room between November 2016 and November 2018. Methods: Practice conformity was assessed according to two explicit criteria: prescription of oral ondansetron and appropriate mean of rehydration. A data collection tool was created and files were reviewed by investigators after standardization. Several secondary outcomes were assessed, including, among others, duration of symptoms, the number of vomiting and diarrhea. The hydration status was measured according to the capillary refill, feeling of skin to the touch, condition of buccal mucosa, tears, heart rate and mental status. These variables were analyzed to understand their impact on practice conformity. We excluded cases in which there was infections needing antibiotics, hypoglycemia, hemodynamic instability, no vomiting in the last 24 hours, convulsions and history of diabetes. Results: A total of 270 patient files were analyzed, 181 of which were included. Oral ondansetron was tried in 49 % of children. Rehydration was adequate in 55% of cases. The hydration level was written in 18% of files and the hydration status noted by the emergency room physician overestimated the dehydration score in 16% of cases. When hydration status was well assessed, adequate rehydration was observed in 63% of cases, while ondansetron was attempted in only 44% of cases. Conclusion: Use of oral ondansetron and adequate mean of rehydration to treat children aged 6 months to 12 years with GE in Chicoutimi emergency department is suboptimal. The difficulty of adequate dehydration assessment may be one of the causes. Concerted dehydration assessment grid and a group prescription for the administration of ondansetron during the nurse triage may constitute potential solutions.
P068: Interrelationship between spatial abilities, anatomy knowledge and technical skills performance: a systematic review
Authors: Langlois J. , Bellemare C. , Toulouse J. , Wells G.
Published: May 2020

Introduction: Spatial ability has been defined as a skill in representing, transforming, generating and recalling symbolic, non-linguistic information. Two distinct human spatial abilities have been identified: visualization and orientation. A sex difference in spatial abilities favouring male has been documented. A pattern of negative effects with increasing age on spatial abilities has also been demonstrated. Spatial abilities have been correlated to anatomy knowledge assessment using practical examination, three-dimensional synthesis from two-dimensional views, drawing of views, and cross-sections in a systematic review. Spatial abilities have also been correlated to technical skills performance in beginners and intermediate learners in a systematic review. The objective of this study was to conduct a systematic review of the interrelationship between spatial abilities, anatomy knowledge and technical skills. Methods: Search criteria included ‘spatial abilities’, ‘anatomy knowledge’ and ‘technical skills’. Keywords related to these criteria were identified. A literature search was done up to November 9, 2018 in Scopus and in several medical and educational databases on Ovid and EBSCOhost platforms. A bank of citations was obtained and was reviewed independently by two investigators. Citations related to abstracts, literature reviews, theses and books were excluded. Articles related to retained citations were obtained and a final list of articles was established. Methods relating spatial abilities testing, anatomy knowledge assessment and technical skills performance were identified. Results: A series of 385 titles and abstracts was obtained. After duplicates were removed and selection criteria applied, 11 articles were retained, fully reviewed, and subsequently excluded with reasons. Conclusion: No eligible articles were found in a systematic review of the interrelationship between spatial abilities, anatomy knowledge and technical skills. The outcome of future studies could help to further understand the cognitive process involved in learning a technical skill in Emergency Medicine.
P075: Targeted temperature management was associated with worse outcomes of non-shockable out of hospital cardiac arrest
Authors: Kawano T. , Grunau B. , Scheuermeyer F. , Fordyce C. , Stenstrom R. , Christenson J.
Published: May 2020

Introduction: We sought to assess the effect of in-hospital targeted temperature management (TTM) on outcomes of non-shockable out-of-hospital cardiac arrest (OHCA). Methods: This is a secondary analysis of a randomized controlled trial “A Randomized Trial of Continuous Versus Interrupted Chest Compressions in Out-of-Hospital Cardiac Arrest” (NCT01372748). We included non-traumatic comatose OHCAs with non-shockable rhythm who survived to hospital admission. Outcomes of interest were survival at hospital discharge and favorable neurological outcome (modified Rankin scale 0-3). We performed multivariable logistic regression, adjusting for baseline characteristics to determine the association between TTM and outcomes, compared to no TTM, for the entire cohort as well as for the propensity matched cohort. Results: Of 1,985 OHCAs who survived to hospital admission, 780 (39.3%) were managed with TTM. In TTM patients, 7.3 % patients survived to hospital discharge and 3.9 % had a favorable neurological outcome in contrast to 10.2 % and 6.1 %, respectively, in no TTM patients. Multivariable analyses demonstrated an association between TTM and decreased probability of both outcomes, compared to no TTM (adjusted ORs for survival: 0.67 95% CI 0.48–0.93, and for favorable neurological outcome: 0.57 95% CI 0.37–0.90). Propensity score matched analyses demonstrate the similar results. Conclusion: TTM might decrease the probability of neurologically intact survival for non-shockable OHCAs.
P080: Trauma experiences of rural emergency physicians: a self assessment
Authors: Jamil M. , Oyedokun T. , Stempien J. , Malik R. , Goodridge D.
Published: May 2020

Introduction: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) practitioners are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. Our goal is to enhance rural trauma care by identifying obstacles rural EM physicians face in Saskatchewan. Methods: This was a cross sectional survey study, emailed to family physicians practicing rural EM in Saskatchewan identified through the Saskatchewan Medical Association database. Inclusion criteria included physicians who are providing EM care currently or within the past year. Rural was assumed to be communities in Saskatchewan that were outside of Saskatoon and Regina. The survey was an anonymous self-assessment regarding demographics, training, hospital resources and comfort. Results: 113 physicians of the 479 rural physicians agreed to participate, 78 met our inclusion criteria. Most (67%) were from communities with less than 10,000 population, 70% had less than 300 ED visits per month. Most (68%) were less than 45 years of age. In terms of training, 57% had completed undergraduate training out of Canada and 63% had completed residency training in Canada. Most had been practicing for more than 2 years (76%). Most (59%) had current ATLS credentials, however only 37% had ever completed the EDE course. Regarding available resources, most centers had plain radiography (99%), POCUS (68%), PRBC (78%) and TXA (93%). However, fresh frozen plasma (41%) and platelets (26%) were not widely available. Comfort was measured on a Likert scale. The types of trauma that respondents were least comfortable with included pediatric (39%), vascular (46%), spine (56%) and genitourinary (60%). The types skills that participants were least comfortable with included pericardiocentesis (19%), and surgical airway (25%). The majority had not performed Pediatric endotracheal tube insertion (79%), surgical airways (99%), pericardiocentesis (99%), central venous line placement (80%) and needle thoracentesis (71%) within the past 12 months. Conclusion: This self-assessment helped us identify aspects of rural trauma medicine that are the most challenging for rural practitioners. Understanding the most difficult challenges in light of the critical resources available to rural trauma medicine providers will inform future professional development initiatives.
P083: Demographic characteristics of people experiencing homelessness presenting to emergency departments
Authors: Burcul I. , Dai J. , Ma Z. , Jamani S. , Hossain R. , Strobel S.
Published: May 2020

Introduction: Despite the visibility of the homeless population, there is limited data on the information of this patient population. Point-in-time counts and survey data from selected samples (such as those admitted to emergency shelter) have primarily been used. This literature suggests that this hard-to-reach population has high rates of presentation at emergency departments (EDs), and as such, EDs often become their main point of contact for health and social services. Leveraging this fact and administrative data we construct a crude census of homeless persons within Ontario. We further examine demographic characteristics of patients experiencing homelessness, and compare this data to findings from previous literature. Methods: All routinely collected administrative health data from EDs located within Ontario, Canada from 2010-2017 were analyzed to examine patient characteristics. Individuals experiencing homelessness were identified by a marker that was adopted in 2009 replacing their recorded postal code with an XX designation. s. Aggregating by LHIN, date and week of year, we examine the overall number of patients experiencing homelessness and number by LHIN location and seasonality. Demographic outcomes examined include age and sex. Results: 640,897 visits to the ED over 7 years were made by 39,525 unique individuals experiencing homelessness. Number of ED visits has steadily increased over 10 years in all of Ontario, despite decline in shelter use for individuals. Presentations were concentrated in large urban centres like Toronto, Ottawa and Hamilton. Fewer presentations occur in the spring and summer months and rise in the winter. Male patients presented older and in greater numbers than female patients. The modal female age of presentation is in the 20-24 age category. The modal male age of presentation is in the 25-29 age category. Older male patients were more likely to have multiple presentations. Conclusion: The utilization of administrative health data offers a novel, cost-effective method to measure demographic characteristics of people experiencing homelessness. Identifying characteristics of homeless patients through this method allows for a more complete understanding of the characteristics of a hard-to-reach population, which will allow policy makers to develop appropriate services for this sub-group. Furthermore, through analysis of trends of demographics over time, changes in the homeless population can be tracked in real-time to allow for coordination and implementation of services in a time-sensitive manner.
P090: Validation of a palliative or end of life care case-finding measure in emergency medical services
Authors: Goldstein J. , Carter A. , Harrison M. , Arab M. , Stewart B. , Jensen J. , Muise A.
Published: May 2020

Introduction: The novel Paramedics Providing Palliative Care at Home program has been developed to address the mismatch between traditional paramedic practice and patient's goals of care. Case-finding is key to estimate potential impact for systems looking to establish such programs, continuous quality improvement once operational, and for prospective identification of patients who might benefit from referral to palliative care. Typical paramedic charting templates do not provide direct identification of these cases. Our objective was to test the validity of a previously derived Palliative Support Composite Measure (PSCM) and two modifications. Methods: A priori Gold Standard criteria for determining whether a response was appropriate for a paramedic palliative care approach were identified by expert consensus. Excluding chief complaints and clinical conditions that were universally identified as not appropriate for paramedic palliative support, these criteria were applied by two trained chart abstractors to 500 consecutive charts to classify calls as appropriate for paramedic palliative support, or not. The PSCM and modifications (added criteria call location type and registration in a palliative care program, text mining terms) were applied to the same cohort, and sensitivity, specificity, positive and negative predicative (PPV/NPV) values calculated. Results: Of the 500 cases, 21 (4.2%) were classified as appropriate for paramedic palliative support by the Gold Standard (kappa 0.734). 9 cases with initial disagreement were reviewed with 8 ultimately being deemed to fit the palliative support criteria. The PSCM performed poorly (using the “potential palliative” cut point): sensitivity 71.4% (95%CI: 47.8-88.7), specificity 71.4% (95%CI: 67.1-75.4) and PPV of 9.9% (95%CI: 7.5-12.9) and NPV of 98.3% (95%CI: 96.7-99). The modified PSCM: sensitivity 61.9% (95% CI: 38.4-81.9), specificity 99% (95%CI: 97.6-99.7), PPV 72.2% (95%CI: 50.5-86.9) and NPV 98.3% (95%CI: 97.2-99). A Modified PSCM plus pall* text term performed similarly: sensitivity100% (83.9-100), specificity 97.3% (95% CI: 95.4-98.5), PPV 61.8% (95%CI: 48.6-73.4) and NPV100%. Conclusion: A modified PSCM provides moderate sensitivity, specificity and PPV, improved by the text term Pall* if feasible. This query will be helpful to systems considering a paramedic palliative care program or when one is already operational.
P095: Bridging knowledge gaps in anaphylaxis management through a video-based educational tool
Authors: Gabrielli S. , Karim J. , Torabi B. , Byrne A. , De Schryver S. , Gadoury-Lévesque V. , Alizadehfar R. , McCusker C. , Vincent M. , Morris J. , Gerdts J. , Ben-Shoshan M.
Published: May 2020

Introduction: Cases of anaphylaxis in children are often not appropriately managed by caregivers. We aimed to develop and to test the effectiveness of an education tool to help pediatric patients and their families better understand anaphylaxis and its management and to improve current knowledge and treatment guidelines adherence. Methods: The GEAR (Guidelines and Educational programs based on an Anaphylaxis Registry) is an initiative that recruits children with food-induced anaphylaxis who have visited the ED at the Montreal Children's Hospital and at The Children's Clinic located in Montreal, Quebec. The patients and parents, together, were asked to complete six questions related to the triggers, recognition and management of anaphylaxis at the time of presentation to the allergy clinic. Participants were automatically shown a 5-minute animated video addressing the main knowledge gaps related to the causes and management of anaphylaxis. At the end of the video, participants were redirected to same 6 questions to respond again. To test long-term knowledge retention, the questionnaire will be presented again in one year's time. A paired t-test was used to compare the difference between the baseline score and the follow-up score based on percentage of correct answers of the questionnaire. Results: From June to November 2019, 95 pediatric patients with diagnosed food-induced anaphylaxis were recruited. The median patient age was 4.5 years (Interquartile Range (IQR): 1.6–7.4) and half were male (51.6%). The mean questionnaire baseline score was 0.77 (77.0%, standard deviation (sd): 0.16) and the mean questionnaire follow-up score was 0.83 (83.0%, sd: 0.17). There was a significant difference between the follow-up score and baseline score (difference: 0.06, 95% CI: 0.04, 0.09). There were no associations of baseline questionnaire scores and change in scores with age and sex. Conclusion: Our video teaching method was successful in educating patients and their families to better understand anaphylaxis. The next step is to acquire long-term follow up scored to determine retention of knowledge.
P097: The emergency department experience for patients and caregivers referred from an outpatient oncology clinic
Authors: Freymond M. , O'Connor E.
Published: May 2020

Introduction: Outpatient oncology clinics have become the mainstay of cancer treatment, but their limited services and hours of operation often lead to emergency department (ED) referrals. With Canada's aging population and cancer survival rates improving, cancer-related ED visits are becoming a significant aspect of emergency medicine. A cancer-related visit to the ED is associated with unique challenges for patients, their caregivers and clinicians. This study focuses on understanding the ED experience of patients and their caregivers sent from an outpatient oncology clinic to a separate affiliated large academic hospital. Methods: A descriptive, phenomenological study of interviews was conducted using the method of Giorgi. The sample included 12 participants (n = 9 patients, 3 caregivers) referred to the ED at a large academic hospital (i.e., Toronto General Hospital, TGH) following a same-day outpatient oncology appointment at an affiliated cancer centre (i.e., Princess Margaret Hospital, PMH). Interviews continued until thematic saturation. All transcripts were analyzed by 2 reviewers with bracketing to ensure accuracy. Results: Four themes were identified from analysis: (1) communication; (2) expectations; (3) care and symptom management and (4) potential improvements. Overall patients and caregivers felt communication between PMH and TGH, and from providers could have been better. Many felt there was a break-down in communication as they did not expect to go through the usual ED triage process, which caused additional anxiety and frustration with the wait times. The majority felt their symptoms were managed in a timely manner and reported the staff to be friendly, caring and professional; however, often felt forgotten and anxious due to a lack of “checking-in”. Their experience could have been improved by receiving more information on the process, a more welcoming environment and separate waiting area or private room for those who are immunocompromised. Conclusion: Although referral from an outpatient oncology clinic to the ED of an affiliated hospital is a common process within Canada, this is the first study to explore the patient and caregiver experience. Understanding the patient and caregiver experience is valuable for identifying quality improvement initiatives. Our analysis revealed the patient and caregiver experience could be improved with better communication and expectation setting regarding the ED process before and throughout the visit.
P098: Patterns of utilization and time-course of events for cancer-related emergency department visits following same-day outpatient oncology appointments
Authors: Freymond M. , O'Connor E.
Published: May 2020

Introduction: Nearly 50% of Canadians will develop cancer in their lifetime (1), and the vast majority of those with cancer will visit the emergency department (ED) in their last 6 months of life (2). Considering the aging population, improvement in cancer survival and current practice of managing cancer in outpatient settings, cancer-related emergencies are becoming a significant aspect of emergency medicine. The presenting symptoms and rates of hospitalization for cancer-related ED visits have largely been established. The current study characterizes the patterns of ED utilization and time-course of events for cancer-related ED visits following same-day outpatient oncology appointments resulting in admission to hospital compared to those not admitted. Methods: A retrospective chart-review was used to identify 231 adult patients who visited the ED at a large academic hospital (i.e., Toronto General Hospital) following a same-day outpatient oncology appointment at an affiliated cancer centre (i.e., Princess Margaret Hospital) from March to May 2019, using administrative data. Results: All visits occurred on weekdays (avg = 4 visits/d) and 57% of visits resulted in hospitalization. Between those admitted and not admitted to hospital, there was no difference in triage time [17:23 + 0:14 vs. 17:01 + 0:20 h, p = 0.47; mean(SD)]. Visits resulting in hospitalization were more urgent (median CTAS score = 2 vs. 3, p < 0.001) and required more consultation services (64 vs. 17 % of visits, p < 0.001), but did not differ for imaging (36 vs. 33 % of visits, p = 0.63). The length of stay in the ED was longer for those admitted [16.6(0.9) vs. 5.3(0.3) h, p < 0.01), they waited longer for their initial assessment [2.6(1.9) vs. 1.8(1.3) h, p < 0.01) and spent 10.1(9.9) h waiting for a bed on the ward. There was no difference in time from initial assessment to disposition, imaging or consult reports (p > 0.05) between groups. The patients transferred from oncology clinics were triaged at 17:13(0:11) h compared to 13:56(0:03) h for all ED visits during the same time frame. Conclusion: Most patients sent from oncology clinics to the ED are admitted, and when admitted they spend an additional 10 h waiting for a bed on the ward. These patients tend to arrive later in the day compared to other ED patients. Understanding utilization patterns and time-course of events allows for objective identification of quality improvement initiatives. 1 Canadian Cancer Society, 2015 2 Barbera et al. CMAJ, 2010
P102: What are Canadian emergency physicians’ attitudes toward, understanding of, and willingness to treat patients who have attempted suicide?
Authors: Fernandes J. , Chakraborty A. , Scheuermeyer F. , Barbic S. , Barbic D.
Published: May 2020

Introduction: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) attitudes toward and understanding of individuals who have attempted suicide. Methods: We developed a web-based survey on attitudes around suicide, which was pilot tested by two EPs and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. We used the Understanding of Suicidal Patients (USP) Scale, an 11-point questionnaire utilized in previous studies to assess healthcare providers’ attitudes toward individuals who have attempted suicide. Each question was graded as a five-point Likert, with a score of 1 indicating complete agreement and a 5 indicating complete disagreement. A total USP score is calculated by adding together the score from each question and ranges from 11 to 55; a lower score indicates greater empathy and understanding of individuals who have attempted suicide. Results: 193 EPs responded to the survey, with 42% of EPs practicing in Ontario. 35% of EPs were female, the mean age was 48 (95% CI 47.3-48.7), and mean years in practice was 17 (95% CI 16.3-17.7). Academic practice location was reported by 55% of EPs, and 81% reported access to an inpatient psychiatry service. The mean USP score was 21.8 (95% CI 21.1-22.5) with a Cronbach's alpha of 0.75, the median was 22 [IQR 14-29]. The item that had most agreement from EPs was “I would like to help a person who has attempted suicide” (1.58, 95% CI 1.50-1.67), while the item that had the least agreement was “patients who have attempted suicide are usually treated well in my work unit” (2.54, 95% CI 2.40-2.69). Conclusion: Canadian EPs have a generally positive attitude toward treating individuals who have attempted suicide. EPs scored highly on a scale that measured willingness to provide care for and empathize with suicidal patients, yet identified that overall care for these patients could be improved.
P105: Observational study of distribution of time and activities over the course of an emergency physician's shift
Authors: Feng E. , Zia Z. , Tong C. , Cornell N.
Published: May 2020

Introduction: The growing scrutiny to improve Emergency Department (ED) wait times and patient flow have resulted in many efforts to increase efficiency and maximize patient throughput via systems improvements. This study investigates areas of efficiency improvement from the Emergency Physician (EP) perspective by examining EP workflow in a two phased observational time-motion study. In the initial phase, the distribution of time and activities of EPs were dissected to identify potential sources for streamlining to maximize physician productivity. The first phase was of the study was completed during the period immediately preceding the implementation of an Electronic Health Records (EHR). The second phase of the study will repeat the analysis one year post EHR implementation. This data will be dissected to again identify sources for streamlining in an EHR environment and to identify shifts in work flow from a paper-based system. Methods: An observational time motion study was conducted at St. Mary's Hospital ED, in Kitchener Ontario. An observer was paired with an EP for the duration of an 8 hour shift, to a total of 14 shifts in the first phase of the study. Nine task categories were measured concurrently with a stopwatch application on a tablet, along with the number of interruptions experienced by the EP. Means of each category were calculated and converted to percentages, representing the amount of time per 8 hour shift dedicated to each activity. The second phase will be repeated in Fall 2020, 1 year after EHR implementation. Results: A total of 14 shifts were observed, accounting for 112 hours of observation. EP's time was allocated amongst the following categories: direct patient interaction (40.8%), documentation (27.1%), reviewing patient results (18.4%), communicating with ED staff (7.63%), personal activities (5.7%), writing orders (5.1%), communicating with consultants (3.3%), teaching (1.7%) and medical information searches (1.3%). On average, EPs experienced 15.8 interruptions over the course of an 8 hour shift. Conclusion: In a paper charting system, the direct patient interaction accounts for the largest timeshare over the course of a given shift. However, the next two largest categories, documentation and reviewing patient data, both represent areas of potential streamlining via clerical improvements. Additionally, detailed measurements of EPs’ activities have proven feasible and provides the potential for future insight into the impact of EHR's on EP workflow.
P111: Kussmaul's sign for the diagnosis of right ventricular myocardial infarction
Authors: Dubé E. , Crozier M. , Middleton A. , Best B.
Published: May 2020

Introduction: Kussmaul's sign, the absence of a drop in JVP or a paradoxical increase in JVP on inspiration, can be elicited clinically as an indicator of right ventricular myocardial infarction (RVMI). RVMI poses unique diagnostic and management challenges. It complicates 30-50% of inferior MI and is associated with increased mortality when compared to inferior MI without RV involvement. Early recognition allows maintenance of preload by avoiding use of nitroglycerin, diuretic and narcotic medication, and treatment with fluids and vasopressors. We reviewed the evidence for Kussmaul's sign for diagnosis of RVMI. Methods: We conducted a librarian assisted search using PubMed, Medline, Embase, the Cochrane database, relevant conference abstracts from 1965 to October 2019. No restrictions for language or study type were imposed. All studies with patients presenting with acute myocardial infarction were reviewed. Two independent reviewers extracted data from relevant studies. Studies were combined when similar study populations were present. Study quality was assessed using the QUADAS-2 tool. Random effects meta-analysis was performed using metaprop in Stata for the 3 reference standards combined. Subset analysis for each of the 3 reference standards was completed. Results: We identified 122 studies: 10 were selected for full text review. Eight studies had comparable populations with a total of 469 consecutive patients admitted to the coronary care unit with acute inferior myocardial infarction and were included in the analysis. Prevalence of RVMI was 36% (CI 95% 31.8–40.5). References standards for the diagnosis of RVMI included echocardiography, 16 lead ECG and haemodynamic studies. A gold standard for diagnosis of RVMI is lacking and thus the reference standards were combined. Kussmaul's sign had a sensitivity of 69.3% (CI 95% 46.3 - 85.5, I2- 86.7%), specificity of 95.1% (CI 95% 75.6 - 99.2, I2- 89.3%) and LR + 14.1 (CI 95% 2.6-73.2). Subset analysis of echocardiography, ECG and haemodynamic studies revealed sensitivity of 45%, 77% and 82% (I2- 62%, N/A, 70%) respectively and specificity of 92%, 84% and 92% (I2- 86%, N/A, 86%). Conclusion: Kussmaul's sign is specific for acute right ventricular myocardial infarction and may serve as an important clinical sign of right ventricular dysfunction requiring preload preserving management.
P114: Barriers and facilitators affecting implementation of a decision aid for the diagnosis of acute aortic syndrome: a qualitative study
Authors: Dmitriew C. , Ohle R.
Published: May 2020

Introduction: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed in order to reduce the frequency of misdiagnoses and number of diagnostic tests. As part of the guidelines, a clinical decision aid was developed in order to facilitate clinician decision-making based on practice recommendations. The objective of this study was to identify barriers and facilitators among physicians to implementation of the decision aid. Methods: We conducted semi-structured interviews with emergency room physicians working at 5 sites distributed between urban academic and rural settings. We used purposive sampling, contacting ED physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators affecting the probability of decision aid uptake and accurate application of the tool. Two independent raters coded interview transcripts using an integrative approach to theme identification, combining an inductive approach to identification of themes within an organizing framework (Theoretical Domains Framework), discrepancies in coding were resolved through discussion until consensus was reached. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification while reducing resource use and missed diagnoses. Facilitators identified included validation and publication of the guidelines as well as adoption by peers. Barriers to implementation and application of the tool included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. Furthermore, scoring components were, at times, out of alignment with clinician practices and understanding of risk factors. The complexity of the decision aid was also identified as a potential barrier to accurate use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use, particularly within rural contexts. Key barriers identified included the complexity of scoring and inclusion criteria, and the variable acceptance of D-dimer among clinicians. These barriers should be addressed prior to implementation of the decision aid during validation studies of the clinical practice guidelines.
P119: Emergency department census is useful as a real-time measure of crowding
Authors: Clouston R. , Howlett M. , Canales D. , Fraser J. , Sohi D. , Lee S. , Atkinson P.
Published: May 2020

Introduction: Crowding is associated with poor patient outcomes in emergency departments (ED). Measures of crowding are often complex and resource-intensive to score and use in real-time. We evaluated single easily obtained variables to establish the presence of crowding compared to more complex crowding scores. Methods: Serial observations of patient flow were recorded in a tertiary Canadian ED. Single variables were evaluated including total number of patients in the ED (census), in beds, in the waiting room, in the treatment area waiting to be assessed, and total inpatient admissions. These were compared with Crowding scores (NEDOCS, EDWIN, ICMED, three regional hospital modifications of NEDOCS) as predictors of crowding. Predictive validity was compared to the reference standard of physician perception of crowding, using receiver operator curve analysis. Results: 144 of 169 potential events were recorded over 2 weeks. Crowding was present in 63.9% of the events. ED census (total number of patients in the ED) was strongly correlated with crowding (AUC = 0.82 with 95% CI = 0.76 - 0.89) and its performance was similar to that of NEDOCS (AUC = 0.80 with 95% CI = 0.76 - 0.90) and a more complex local modification of NEDOCS, the S-SAT (AUC = 0.83, 95% CI = 0.74 - 0.89). Conclusion: The single indicator, ED census was as predictive for the presence of crowding as more complex crowding scores. A two-stage approach to crowding intervention is proposed that first identifies crowding with a real-time ED census statistic followed by investigation of precipitating and modifiable factors. Real time signalling may permit more standardized and effective approaches to manage ED flow.
P120: A survey of Ontario Family Health Teams: Family physicians are reliant on emergency services for complicated early pregnancy loss
Authors: Cirone J. , Thompson C. , McLeod S. , Varner C.
Published: May 2020

Introduction: The majority of first trimester pregnancy care in Canada is provided by family physicians and emergency departments (EDs). Early pregnancy loss occurs in approximately 30% of pregnancies, and the majority take place in first trimester when many patients do not yet have an obstetrical care provider. In Ontario, nearly 70% of patients are rostered to a family physician, many of whom practice in Family Health Teams (FHTs). The objective of this study was to determine how Ontario family physicians manage early pregnancy complications and explore the services available for patients experiencing early pregnancy loss or threatened early pregnancy loss. Methods: Family physician leads from 104 Ontario FHTs were contacted by email and invited to complete a 19-item, online questionnaire using modified Dillman methodology. The survey was developed by investigators based on a review of relevant literature and consultation with clinical experts. Prior to distribution, the questionnaire was peer reviewed and tested for face and construct validity, as well as ease of comprehension. Results: Respondents from 50 FHTs across Ontario completed the survey (response rate 48.1%). Of the respondents, 45 (90.0%) reported access to an ED in their community, 45 (90.0%) had access to an obstetrician/gynecologist, 33 (66.0%) had access to an early pregnancy clinic, and 18 (36.0%) reported comprehensive obstetrical care from first trimester to delivery within their FHT. The following services were only accessible through the ED: administration of RhoGAM (n = 28; 56.0%); surgical management of spontaneous or missed abortion (n = 22; 44.0%); same day serum quantitative beta human chorionic gonadotropin (n = 21; 42.0%); same day radiologist-interpreted ultrasound assessment (n = 15; 30.0%); and medical management of spontaneous or missed abortion (n = 12; 24.0%). Forty (80.0%) respondents stated physicians in their practice would provide urgent follow-up care for patients with spontaneous abortion, 35 (70.0%) would provide care for threatened abortion, and 26 (52.0%) would provide urgent care for missed abortion. For patients with a stable ectopic pregnancy, 37 (74.0%) respondents would refer to the ED. Conclusion: This study suggests FHTs in Ontario provide comprehensive care to patients with uncomplicated early pregnancy loss such as spontaneous abortion, yet rely on the ED for management of complicated early pregnancy loss, when medical or surgical management is indicated or for ectopic pregnancy.
P130: Feasibility of self-assessing functional status in older emergency department patients
Authors: Boucher V. , Boucher V. , Lamontagne M. , Lee J. , Émond M.
Published: May 2020

Introduction: Geriatric Emergency Department (ED) guidelines recommend systematic screening of older patients for geriatric syndromes. However, compliance issues to this recommendation have already been observed. Self-assessment tools could be an interesting solution as self-assessed general, mental and physical health was shown to be predictive of functional decline and mortality. The Older Americans Resources and Services scale (OARS), is a simple geriatric functional assessment scale that is widely used by professionals to quantify patients’ ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL). However, its use as a self-assessment tool has never been tested. Objective: to evaluate the feasibility of the self-assessed OARS compared to its standard administration by a research assistant (RA) in older ED patients. Methods: A planned sub-analysis of a single center randomized crossover pilot study in 2018 was realized. Patients aged ≥65 who consulted to the ED for any medical reason were included. Patients were excluded if they: 1) required resuscitation (CTAS 1); 2) were unable to consent/to speak French; 3) had a physical condition preventing the use of an electronic tablet. Patients were randomized 1:1 to either 1) tablet-based functional status self-assessment or 2) the RAs questionnaire administration at first, after which they crossed-over to the other assessment method. Paired t-tests were used to assess the score differences. Results: 60 patients were included. Mean age was 74.4 ± 7.6 and 34 (56.7%) participants were women. Mean OARS score according to RA was 25.1 ± 3.3 and mean self-assessed OARS score was 26.4 ± 2.5 (p < 0.0001). There was also differences when looking at the AVQ and AIVQ separately. Mean AVQ scores were 12.5 ± 1.8 and 13.5 ± 0.9 (p < 0.0001) and mean AIVQ scores were 12.6 ± 1.8 and 12.9 ± 1.8 (p = 0.04) for RA assessment and self-assessment, respectively. Conclusion: Our results show a statistically significant difference between RA assessment and patient self-assessment of functional status, and this difference seems to be more pronounced regarding AVQ than AIVQ. The study confirms that self-assessment of functional status by older ED patients is feasible, but further testing is required in order to confirm the validity and psychometric values of this self-administered version of the OARS.
P131: Practice patterns of emergency department physicians administering naloxone for patients with suspected opioid overdose
Authors: Blaszak M. , Chilton S. , Van Aarsen K. , Yan J. , Detombe S. , Knezevic S. , Riggan M.
Published: May 2020

Introduction: Naloxone is recommended for reversing opioid-associated respiratory depression. There is wide variability in emergency department (ED) practice patterns regarding naloxone use, dosing, and observation time post-administration. This study describes the naloxone practice patterns of ED physicians managing suspected opioid overdose patients. Methods: A retrospective chart review was conducted of adult patients (≥ 18 years) presenting to an academic tertiary care centre (consisting of two EDs with an annual census 150,000 visits) in 2017 with suspected opioid overdose who were administered naloxone in the ED. Patients were identified electronically and the following information was abstracted from patient charts: demographics, naloxone dosage and infusion initiation, disposition data, indications for naloxone administration, response to therapy, and adverse effects. Variability in initial and total dose was examined. Initial dose was also compared in those with cardiorespiratory compromise (CPR given, respiratory rate < 8, or desaturation below 89%) using independent samples median tests. Data was analyzed using standard descriptive statistics. Results: 113 patients met inclusion criteria. Indications for naloxone administration were: level of consciousness (50.5%), respiratory depression (4.0%), miosis (1.0%), a combination of factors (19.8%), or undocumented (24.8%). Median initial dose was 0.40 mg (IQR: 0.20-0.40 mg). Median total naloxone administered in the ED was 0.48 mg (IQR: 0.35-1.2 mg). The initial dose resulted in a response in 43.1% of patients, with 36.0% of responding patients later experiencing subsequent respiratory depression. 31% of patients received a naloxone infusion. Initial dose in patients with cardiopulmonary compromise was significantly different only comparing patients who received CPR versus those who did not (median 0.40 mg; IQR: 0.20-0.80 mg; P = 0.019). Four patients experienced emesis following naloxone. Median length of ED stay was 7.0 hours (IQR: 4.0-9.5 hours), and median hospital length of stay was 3.0 days (IQR: 1.0-5.0 days). Median ED observation time prior to discharge was 4.0 hours (IQR: 2.0-8.0 hours). Ultimate disposition home, to the ward, or to the intensive care unit was 47.1%, 42.2%, and 9.8% respectively (1.0% deceased). Conclusion: The dose and usage of naloxone by ED physicians in this study is variable. Further prospective studies are needed to determine the effective naloxone dosing strategy.
P135: Administrative codes for heat illness: a validation study in Ontario, Canada
Authors: Baassiri H. , Varghese T. , Columbus M. , Clemens K. , Yan J.
Published: May 2020

Introduction: Extreme heat events due to climate change are becoming increasingly frequent and severe, and may have an impact on human health. Administrative database studies using International Classification of Diseases 10th revision codes (ICD-10) are powerful tools to measure the burden of acute heat illness (AHI) in Canada. We aimed to assess the validity of the coding algorithm for emergency department (ED) encounters for AHI in our region. Methods: Two independent reviewers retrospectively abstracted data from 507 medical records of patients presenting at two EDs in Ontario between May-September 2015-2018. The Gold Standard definition of an AHI is chart-documented heat exposure with a heat related complaint, such as syncope while working outdoors on a hot day. To determine ICD coding algorithm positive predictive value (PPV), records that were previously coded as ICD-10 heat illnesses were compared to the Gold Standard for AHI. To determine sensitivity (Sn), specificity (Sp) and negative predictive values (NPV), the Gold Standard was compared to randomly selected records. A total of 326,702 ED visits were included in study period with 208 having an ICD-10 code related to heat illness. Sample size calculation demonstrated a need to manually review 62 previously coded heat illnesses and 931 random cases, of which 50 and 474 have been reviewed, respectively. In both abstractions, 20% of cases underwent a blinded duplicate review. Results: In our review of 474 random records, 2 cases were identified as AHI but without an appropriate ICD-10 code, 445 were not AHIs, and no cases had been identified as having an AHI ICD-10 inappropriately applied. In our review of 50 previously coded heat illnesses, 34 were found to be appropriately coded and 16 inappropriately coded, as AHI ICD-10. Average patient age and gender of heat illness vs non-heat illness ED presentations were 32 and 48 years of age and 49% and 64% male, respectively. The leading complaint in AHI was heat stroke/exhaustion (39%), followed by headaches (15%), dizziness (9%), shortness of breath (9%) and syncope/presyncope (6%). 76% of all heat illness presentations presented following a period of physical exertion. Conclusion: Final calculation of Sn, Sp, PPV, NPV for the algorithm will occur upon completion of the review. Preliminary results suggest that ICD-10 coding for AHI may be applied correctly in the ED. This study will help to determine if administrative data can accurately be used to measure the burden of heat illness in Canada.
P141: Education innovation: Equity, Diversity, Advocacy, and Cultural Safety (EDACS) curriculum
Authors: Acton C. , Dell E. , Hayman K.
Published: May 2020

Innovation Concept: Upon completion of training, Canadian physicians are expected to respond to patient needs to advocate for change both within and beyond the immediate clinical environment.1 In the current EM curriculum, residents are not explicitly taught skills necessary to engage in clinical care nor policy change that would improve the social determinants of health (SDOH) of patients. In response to this challenge, we have developed and are piloting a 2 year curriculum on “Equity, Diversity, Advocacy, and Cultural Safety (EDACS), to equip EM trainees with the knowledge and skills to advocate and influence policy - to empower residents to act on healthcare inequities rather than simply be aware of them. Methods: We developed the curriculum utilizing the Structural Competency paradigm, a theoretical framework within which clinical and advocacy skills to address the SDOH at a structural level can be taught and practiced. This paradigm includes five intersecting skill-sets, including recognizing the structures that shape clinical interactions, developing an extra-clinical language of structure, and imagining structural interventions. Curriculum, Tool, or Material: The educational intervention will consist of 8 hour-long sessions and one 3-hour long session held over a 2-year period. The 3-hour long session will consist of a walking tour of sites accessed by individuals living in poverty in the Toronto downtown core, including a homeless shelter, a needle exchange program, and others. This session will be facilitated by a physician lead, with input at each site from community organizers. Prior to the walking tour, residents will receive an introductory session outlining themes to reflect on during and after the walking tour. Hour-long sessions will be delivered by invited healthcare providers with specific clinical expertise in the topics of discussion, which will address the care of and advocacy for various marginalized populations. Conclusion: To our knowledge, this is the first curriculum of its kind being implemented in an EM training program in Canada. Upon completion of the curriculum, students will be able to apply the five skillsets outlined in the Structural Competency Framework to address and improve upon inequitable conditions that influence patients treated in the emergency department. We intend to use formal and informal feedback from residents, clinicians, and lecturers to refine future curriculum cycles, and hope to inform similar programs elsewhere.