bluuebunny/crossref_metadata_2025 huggingface dataset:
P110: Chest tube thoracostomy in the ED: predictors of complications
Authors: Careau M. , Malo C. , Boucher V. , Émond M.
Published: May 2020

Background: Chest tube thoracostomy is frequently performed in the emergency department (ED) for patients with traumatic thoracic injuries. However, this procedure is associated with a high complication rate. Aim Statement: The aim of this study was to describe and assess predictors of complications following chest tube thoracostomy. Measures & Design: A retrospective chart review was conducted in a level 1 trauma center. Patients aged ≥16 who required a chest tube for a traumatic injury between 2016 and 2019 were identified. Variables including demographic data, Charlson Comorbidity Index, mechanism of injury, Injury Severity Score (ISS), chest tube insertion and technique (i.e. position, dislodgement, obstruction, organ perforation), complications and interventions were collected using a standardized data collection form. A second reviewer assessed all ambiguous files. Descriptive statistics and adjusted odds ratios were calculated. Evaluation/Results: 179 patients were included in the study, of which 141 were male (79%). Mean age was 54 18 and median ISS was 17 (Q1-Q3: 9-27). 207 chest tube thoracostomies were performed for pneumothorax (81%) or a hemothorax (38%) mainly after a blunt injury (92%). 183 standard chest tube (88%) and 24 pigtail catheters (12%) were installed. Overall, emergency medicine physicians/residents performed 70% of these procedures and 54% were performed by residents. Sixty-one patients (34%) suffered a total of 73 complications: 45 were infectious (62%) and 28 were technique-related (38%). Pneumonia was the most frequent complication (19%) followed by reintroduced or replaced chest tube (12%). After adjusting for the ISS, there was no statistically significant association between the type of tube (OR 0.36 95% CI: 0.08-1.68), the medical specialty (OR 1.19 95% CI: 0.55-2.58) or the level of training (OR 1.29 95% CI: 0.63-2.64) of the clinician and the incidence of at least one complication. Discussion/Impact: Our results show that one out of three patients experienced at least one complication following a chest tube thoracostomy in the ED, which confirmed existing literature (5%- 38%). After adjustment, the type of tube used, the specialty and level of training of the health professional who performed the procedure was not associated with the incidence of at least one complication.
P116: Colder, but no less safe: A comparison of bicycle related traumas in winter compared to summer cyclists
Authors: Davis S. , Delaney J.
Published: May 2020

Introduction: This study aimed to examine difference in trauma injuries between bicycle users in winter months compared to summer months. Behavioral variables were also examined to assess seasonal variability, as well as associations with traumas. Methods: This was a retrospective cohort study of all bicycle related traumas presenting to a level I trauma center between the years 1998-2018. All data was collected through a standardized trauma database. Seasonal differences were examined by comparing trauma severity and behavior patterns between patients arriving in the months May-September (summer) and those arriving in November-March (winter). Outcome measures included: Injury Severity Scale, GCS, type of accident, helmet use, demographics and alcohol level. Groups were compared using t-tests and Chi-square analysis as appropriate. Results: A total of 980 bicycle related traumas were analyzed. There were a significantly greater number of injuries in the summer as compared to winter months (879 in summer vs. 101 in winter). While most injuries in both groups were rated in the severe range of the Injury Severity Scale, there were no differences in injury severity, initial GCS, deaths, or head injuries between the two seasons. There were also no differences in drug, alcohol, or helmet use. The only significant difference between seasons was that winter riders were more likely to be male. Overall, helmet use was associated with lower injury severity, less head trauma, and a higher initial GCS. Use of alcohol was associated with less likelihood of wearing a helmet. Conclusion: In conclusion, bicycle use in winter does not appear to be associated with worse outcomes than summer. Public health interventions can continue to encourage winter bicycle use, with the encouragement of helmet use and avoidance of alcohol when cycling as an important protective factor in both seasons.
P123: Emergency department utilization by patients with advanced chronic kidney disease and dialysis: A population based study
Authors: Chhibba R. , Leon S. , Rigatto C. , Ferguson T. , Komenda P. , Tangri N.
Published: May 2020

Introduction: Chronic Kidney Disease (CKD) is a potent risk factor for kidney failure, cardiovascular events and all cause hospitalizations. In addition to higher outpatient resource use, patients with CKD may present more frequently to the emergency department (ED) and may be more likely to be admitted for hospitalization. In Manitoba, we previously demonstrated an 8-fold increase in the frequency of ED presentations by patients on dialysis as compared to a non-dialysis population. Comparable data on ED visits remain sparse for patients with CKD G3-G5, not on dialysis. Here, we aim to describe the frequency of ED visits and highlight differences in reasons for visit in patients with CKD stages G3-G5 and those on dialysis when compared to a non-CKD population. Methods: We performed a retrospective cohort study using administrative health data from the Winnipeg Regional Health Authority, Canada. We included all adults (≥ 18 years) with CKD stages G3-G5 and patients undergoing dialysis between January 1st, 2010 and December 31, 2014. Secular trends in the in the rates of ED visits were calculated for those with CKD, those on dialysis and in the non-CKD population. Results: Over the study period, patients undergoing dialysis had the highest incidence of ED visits, followed by patients with CKD and those with normal kidney function (150 vs 106 vs 34 per 100 persons per year respectively). These rates were stable over the period studied. Among the non-CKD population, the most common reasons for an ED visit were musculoskeletal complaints (25.6%), followed by gastrointestinal (11.04%) and cardiovascular complaints (10.26%). In the CKD and dialysis cohort, ED visits were more commonly secondary to cardiovascular complaints (21.54% and 18.99% respectively), followed by respiratory and gastrointestinal complaints. . Admission to hospital was higher in CKD and dialysis populations than in the non-CKD population (29.56%, 26.07% vs 10.61%, respectively). Conclusion: Patients with CKD present frequently to the ED, and are often admitted after presentation. Cardiovascular and respiratory complaints are more common in the CKD population when compared to the general population.
P125: Low dose intravenous ketorolac in renal colic, a pilot randomized controlled trial
Authors: Chao J. , Brasher P. , Cheung K. , Sharma R. , Badke K. , Hohl C.
Published: May 2020

Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) are first-line analgesics for emergency department (ED) patients with renal colic. Lower doses of intravenous (IV) ketorolac may provide similar pain relief to standard dosing in patients with acute pain. Patients with renal colic may be at increased risk of acute kidney injury; exposing them to lower doses of NSAIDs may put them at lower risk while providing equally effective analgesia. We conducted a pilot study to determine the feasibility of a randomized trial comparing the effectiveness and safety of low with standard ketorolac dosing in ED patients with suspected renal colic. The primary objective was to demonstrate the ability to achieve an enrolment target of 2 patients per week. Methods: We enrolled a convenience sample of adults presenting to an academic urban ED with unilateral flank pain suspected to be renal colic. We randomized patients to 10 mg (low dose, intervention) or 30 mg (standard dose, control). Participants, treating physicians and nurses, and researchers were blinded to treatment allocation. Our main feasibility outcome was the recruitment rate. Secondary outcomes were changes in pain scores (0-10) at 30 and 120 minutes post-ketorolac administration, vital signs, adverse events and ED length of stay. Results: We approached 82 patients, of whom 47 (57.3%) were eligible. Of these, 36 consented to participating and 30 were randomized. The proportion of screened patients who were enrolled was 36.6% (30/82). We completed enrolment over a 21-week period, with an average recruitment rate of 1.5 patients/week (range 0-4). The average baseline pain score for all participants was 6.9 (SD = 2.1). At 30 minutes post-ketorolac administration, the low dose group had a mean pain reduction of 2.0 points compared to a pain reduction of 1.7 in standard dose group (difference = 0.3, 90% CI: -0.7 to 1.4). Conclusion: These preliminary results support the possibility that low dose ketorolac may be efficacious in this patient population. We did not meet our target recruitment of 2 patients per week as this was primarily due to restricted recruitment hours. To successfully conduct a larger trial, we would need to expand both recruitment hours and the number of sites.
P132: Optimizing a physician surge protocol to address emergency department wait times during times of increased patient demand
Authors: Bhate T. , Dowling S. , Collins N.
Published: May 2020

Background: Emergency Department overcrowding remains a significant problem. Interventions have often focused on areas external to the ED, with patient flow in the ED receiving less attention. Efforts to address ED flow are complicated by daily fluctuations in patient volume and acuity. Our local protocol brings in additional physicians when internal metrics indicate patient demand can't be met by current physician resources (a ‘surge’ period). However, anecdotal evidence suggests a lack of satisfaction and efficacy. We therefore undertook a project to improve our local management of these surge periods. Aim Statement: To improve the effectiveness of an ED Physician Surge Protocol to allow for a physician scheduling strategy that is reflective of the needs of the ED. Measures & Design: This project consists of 3 phases. Phase 1 was an analysis of current surge metrics (including frequency, temporal patterns and physician response), with concurrent literature search to identify any best practices or easily addressable protocol changes, with first planned PDSA cycle. Phase 2 is a mixed methods survey of local staff to identify barriers and enablers of our current protocol, concurrent with a national survey of current practices. Phase 3 will be the implementation of a revised protocol, followed by a second mixed methods survey and analysis of metrics of interest. Evaluation/Results: Analysis of surge data (Oct 2018-Oct 2019) demonstrated a high volume of surges per month (78.7 +/- 10.9), highest at Foothills Medical Centre (94.3). Across all sites, afternoon periods had highest frequency of surges (absolute peak 1400 - 1500) with a secondary peak 2200–2300, both peaks occurring most frequently on weekends (Fri-Sun) However, physician response to surge calls was < 10% (5.8-9.1%), with no discernable temporal pattern, even accounting for the significant number of automatic surge calls cancelled by clinicians. Analysis of data, in addition to literature review and engagement with senior administration suggested no immediate protocol changes, therefore project moved to 2nd phase. This phase is currently in progress, with planned analysis using Pareto Chart methodology. Discussion/Impact: Our initial data clearly demonstrates that current procedures are inadequate to address this ongoing issue, with no readily apparent solutions. Analysis of local barriers and enablers is currently underway, in addition to a national survey, with the results expected to inform an extensive redesign of current procedures.
P142: Perspectives of medical students and undergraduate students on their experience as medical scribes in the Saint John Regional Hospital Emergency Department
Authors: Abelev I. , Lewis D. , Fraser J. , Atkinson P.
Published: May 2020

Introduction: Electronic medical records (EMR) have placed increasing demand on emergency physicians and may contribute to physician burnout and stress. The use of scribes to reduce workload and increase productivity in emergency departments (ED) has been reported. This objective of this study was to evaluate the educational and experiential value of scribing among medical and undergraduate students. We asked: “Will undergraduates be willing to scribe in exchange for clinical exposure and experience?”; and, “Should scribing be integrated into the medical school curriculum?” Methods: A mixed-methods model was employed. The study population included 5 undergraduate, and 5 medical students. Scribes received technical training on how to take physician notes. Undergraduate students were provided with optional resources to familiarize themselves with common medical terminology. Scribes were assigned to physicians based on availability. An exit interview and semi-structured interviews were conducted at the conclusion of the study. Interviews were transcribed and coded into thematic coding trees. A constructivist grounded theory approach was used to analyze the results. Themes were reviewed and verified by two members of the research team. Results: Undergraduate students preferred volunteering in the ED over other volunteer experiences (5/5); citing direct access to the medical field (5/5), demystification of the medical profession (4/5), resume building (5/5), and perceived value added to the health care team (5/5) as main motivators to continue scribing. Medical students felt scribing should be integrated into their curriculum (4/5) because it complemented their shadowing experience by providing unique value that shadowing did not. Based on survey results, five undergraduate students would be required to cover 40 volunteer hours per week. Conclusion: A student volunteer model of scribing is worthwhile to students and may be feasible; however, scribe availability, potentially high scribe turnover, and limited time to develop a rapport with their physician may impact any efficiency benefit scribes might provide. Importantly, scribing may be an invaluable experience for directing career goals and ensuring that students intrinsically interested in medicine pursue the profession. Medical students suggested that scribing could be added to the year one curriculum to help them develop a framework for how to take histories and manage patients.
LO01: What presenting features predict obstetrical outcomes in women who present to the emergency department with early pregnancy bleeding?
Authors: Burgoyne M. , Clouston R. , Banerjee A. , Fraser J. , Atkinson P.
Published: May 2020

Introduction: Vaginal bleeding in early pregnancy is a common emergency department (ED) presentation, with many of these episodes resulting in poor obstetrical outcome. These outcomes have been extensively studied, but there have been few evaluations of what variables are associated predictors. This study aimed to identify predictors of less than optimal obstetrical outcomes for women who present to the ED with early pregnancy bleeding. Methods: A regional centre health records review included pregnant females who presented to the ED with vaginal bleeding at <20 weeks gestation. This study investigated differences in presenting features between groups with subsequent optimal outcomes (OO; defined as a full-term live birth >37 weeks) and less than optimal outcomes (LOO; defined as a miscarriage, stillbirth or pre-term live birth). Predictor variables included: maternal age, gestational age at presentation, number of return ED visits, socioeconomic status (SES), gravida-para-abortus status, Rh status, Hgb level and presence of cramping. Rates and results of point of care ultrasound (PoCUS) and ultrasound (US) by radiology were also considered. Results: Records for 422 patients from Jan 2017 to Nov 2018 were screened and 180 patients were included. Overall, 58.3% of study participants had a LOO. The only strong predictor of outcome was seeing an Intra-Uterine Pregnancy (IUP) with Fetal Heart Beat (FHB) on US; OO rate 74.3% (95% CI 59.8-88.7; p < 0.01). Cramping (with bleeding) trended towards a higher rate of LOO (62.7%, 95% CI 54.2-71.1; p = 0.07). SES was not a reliable predictor of LOO, with similar clinical outcome rates above and below the poverty line (57.5% [95% CI 46.7-68.3] vs 59% [95% CI 49.3-68.6] LOO). For anemic patients, the non-live birth rate was 100%, but the number with this variable was small (n = 5). Return visits (58.3%, 95% CI 42.2-74.4), previous abortion (58.8%, 95% CI 49.7-67.8), no living children (60.2%, 95% CI 50.7-69.6) and past pregnancy (55.9%, 95% CI 46.6-65.1) were not associated with higher rates of LOO. Conclusion: Identification of a live IUP, anemia, and cramping have potential as predictors of obstetrical outcome in early pregnancy bleeding. This information may provide better guidance for clinical practice and investigations in the emergency department and the predictive value of these variables support more appropriate counseling to this patient population.
LO02: Direct laryngoscopy: is it becoming a lost art in resident education?
Authors: Botros C. , Renschler C. , Dullemond K. , Yoo J. , Trojanowski J.
Published: May 2020

Introduction: Intubation is one of the highest-risk procedures performed in the emergency department (ED) on a regular basis. The British Columbia Airway Registry for Emergencies (BCARE) Network collects data from every ED intubation at two tertiary care centres and one community centre and serves as a valuable quality improvement tool. We compared intubation techniques, success, and complication rates between emergency medicine physicians and trainees. Methods: We completed an observational study of all patients intubated in the ED by resident trainees or attending physicians over a period of 28 months from July 2017 to November 2019. Respiratory therapists (RTs) completed a standardized data collection form after every intubation and the data was used to analyze techniques, success, and complication rates. Form completion compliance was periodically reviewed by cross-referencing patient names in the BCARE network with the radiology database for chest x-rays that were performed after intubation in the hospital. Results: 642 intubations were performed by EM physicians: 66 by PGY1-2 residents,141 by PGY3-5 residents, and 435 by staff physicians. Airway assessment prior to intubation was completed by PGY1-2 in 78.1% of cases, PGY3-5 in 67.9%, and staff in 62.6%. Direct laryngoscopy (DL) was chosen as first-choice technique 24.2% by PGY1-2, 24.8% by PGY3-5, and 30.1% by attending physicians. Bougie was used 2.7% of cases for all groups. First-pass success was 78.8% for PGY1-2, 86.5% for PGY3-5, and 85.7% for staff. Mean number of attempts were similar at 1.24, 1.18, and 1.20 for R1-2, R3-5, and staff, respectively. There were similar complication rates between all groups, on average 16.9%, with the most common being hypoxemia prior to induction, and desaturation following induction. There was a higher rate of staff performing second intubation attempts following junior residents (50.0%) than senior residents (26.3%). Conclusion: Trainees have a stronger preference to use video laryngoscopy (VL) than staff physicians as their first-line technique. Success rates were similar between senior residents and attending physicians, but significantly lower in junior residents, despite number of attempts being similar between the three groups. Complication rates were similar among all 3 groups. This data may suggest that a stronger emphasis for DL use among trainees is important.
LO03: Prospective comparative evaluation of the ESC 1-hour and a 2-hour rapid diagnostic algorithm for myocardial infarction using high-sensitivity troponin-T
Authors: Andruchow J. , Boyne T. , Seiden-Long I. , Wang D. , Vatanpour S. , Innes G. , McRae A.
Published: May 2020

Introduction: Rapid diagnostic algorithms using high-sensitivity cardiac troponin can rapidly diagnose or exclude acute myocardial infarction (MI). However, multiple algorithms have been proposed and it is unclear if some outperform others. The objective of this study was to prospectively compare the diagnostic performance of 1- and 2-hour algorithms in clinical practice in a Canadian population. Methods: Emergency department patients with chest pain had high-sensitivity cardiac troponin-T (hs-cTnT) collected on presentation and 1- and 2-hours later at a single academic tertiary hospital and regional percutaneous coronary intervention site over a 2-year period. The primary outcome was index MI, the secondary outcome was 30-day major adverse cardiac events (MACE). All outcomes were 2 physician adjudicated. Results: We enrolled 1,167 patients with hs-cTnT collected on ED presentation. Of these, 350 had a valid 1-hour and 550 had a 2-hour hs-cTnT sample. Index MI prevalence was ~11%. Sensitivity of the 1- and 2-hour algorithms for index MI was 97.3% (95% CI 85.8-99.9%) and 100% (95% CI 91.6-100%) and for 30-day MACE was 80.9% (95% CI 66.7-90.9%) and 83.3% (95% CI 73.2-90.8%), respectively. The 1-hour algorithm was 96.3% specific for index MI (95% CI 93.8-98.2%) whereas specificity for the 2-hour algorithm was 97.9% (95% CI 96.3-100%). Both algorithms classified about one-quarter of patients in an indeterminate observational zone with an ~11% MI prevalence. Conclusion: Both the 1- and 2-hour algorithms were highly sensitive and specific for MI, but were less sensitive for 30-day MACE. However, the 2-hour algorithm trended toward better performance, likely because its larger delta cutoffs reduce the risk of misclassification owing to analytic variability. These findings suggest algorithms using larger delta cutoffs may provide a greater margin of safety. Further comparative evaluation of rapid diagnostic algorithms using different cutoffs and characterization of patients in the observational zone is warranted.
LO05: Rate of prescription of oral anticoagulation in patients presenting with new onset atrial fibrillation/flutter
Authors: Hatam E. , Ghate G. , Columbus M. , Garvida C. , Aarsen K. Van
Published: May 2020

Introduction: Atrial fibrillation (AF) and atrial flutter (AFL) are two common arrhythmias that present to the emergency department (ED) and are a major risk factor for stroke. The 2014 Canadian Cardiovascular Society (CCS) guidelines recommend starting oral anticoagulation (OAC) upon ED discharge for patients with CHADS65 scores of ≥1 to reduce stroke risk. The goal of this study was to identify whether the ED patient population presenting with new onset AF/AFL with CHADS65 ≥ 1 are appropriately initiated on OAC by ED physicians. Methods: This was a retrospective chart review (Jan-Dec 2017) of ED visits at two academic hospitals in Ontario. The year 2017 was chosen to allow for adequate time from the publishing of the CCS guidelines for uptake into clinical practice. Inclusion criteria: patients with a new diagnosis of AF/AFL who are discharged by ED physicians. Exclusion criteria: patients with a history of AF/AFL, already on OAC, admitted to hospital, presenting with arrhythmia other than AF/AFL, and charts without adequate information to calculate CHADS65 score. Charts were reviewed in detail to assess CHADS65 score, ED physician decision to prescribe OAC, referral rates to outpatient clinics and timing of follow up. Results: A total of 1272 charts were reviewed. 1124 were excluded. 148 charts were identified as patients with new onset AF/AFL presenting to the ED who were discharged by ED physicians. 24/148 (16%) were appropriately prescribed OAC. 124/148 (84%) were not prescribed OAC. Of these 40/124 (32%) were CHADS65 0 while the other 84/124 (67%) were CHADS65 ≥ 1 who should have been considered for OAC. Further review determined that 78/84 (92%) were referred to outpatient clinics for the decision regarding OAC with the mean (SD) number of days to follow up being 11(±15). Importantly 1/84 (1.2%) returned prior to their scheduled appointment with a stroke. Only 6/84 (7%) had no follow up arranged. Conclusion: Overall, we found that the rate of OAC prescription by ED physicians for patients being discharged with a new diagnosis of AF/AFL with a CHADS65 score ≥1 was 16%. This is despite the CCS 2014 recommendation of starting OAC for all patients with a CHADS65 score ≥1. It appears that ED physicians are continuing to defer the decision to prescribe OAC to outpatient clinics. Further projects can explore barriers to application of the CCS guidelines and create knowledge translation tools.
LO06: Development of practice recommendations for ED management of syncope by mixed methods
Authors: Thiruganasambandamoorthy V. , Taljaard M. , Hudek N. , Brehaut J. , Ghaedi B. , Nguyen P. , Sivilotti M. , McRae A. , Yan J. , Ohle R. , Fabian C. , Le Sage N. , Mercier E. , Hegdekar M. , Huang P. , Nemnom M. , Krahn A. , Archambault P. , Presseau J. , Graham I. , Rowe B.
Published: May 2020

Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.
LO08: A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with atrial flutter
Authors: Stiell I. , Sivilotti M. , Taljaard M. , Birnie D. , Vadeboncoeur A. , Hohl C. , McRae A. , Rowe B. , Brison R. , Thiruganasambandamoorthy V. , Macle L. , Borgundvaag B. , Morris J. , Mercier E. , Clement C. , Brinkhurst J. , Brown E. , Nemnom M. , Wells G. , Perry J.
Published: May 2020

Introduction: For rhythm control of acute atrial flutter (AAFL) in the emergency department (ED), choices include initial drug therapy or initial electrical cardioversion (ECV). We compared the strategies of pharmacological cardioversion followed by ECV if necessary (Drug-Shock), and ECV alone (Shock Only). Methods: We conducted a randomized, blinded, placebo-controlled trial (1:1 allocation) comparing two rhythm control strategies at 11 academic EDs. We included stable adult patients with AAFL, where onset of symptoms was <48 hours. Patients underwent central web-based randomization stratified by site. The Drug-Shock group received an infusion of procainamide (15mg/kg over 30 minutes) followed 30 minutes later, if necessary, by ECV at 200 joules x 3 shocks. The Shock Only group received an infusion of saline followed, if necessary, by ECV x 3 shocks. The primary outcome was conversion to sinus rhythm for ≥30 minutes at any time following onset of infusion. Patients were followed for 14 days. The primary outcome was evaluated on an intention-to-treat basis. Statistical significance was assessed using chi-squared tests and multivariable logistic regression. Results: We randomized 76 patients, and none was lost to follow-up. The Drug-Shock (N = 33) and Shock Only (N = 43) groups were similar for all characteristics including mean age (66.3 vs 63.4 yrs), duration of AAFL (30.1 vs 24.5 hrs), previous AAFL (72.7% vs 69.8%), median CHADS2 score (1 vs 1), and mean initial heart rate (128.9 vs 126.0 bpm). The Drug-Shock and Shock only groups were similar for the primary outcome of conversion (100% vs 93%; absolute difference 7.0%, 95% CI -0.6;14.6; P = 0.25). The multivariable analyses confirmed the similarity of the two strategies (P = 0.19). In the Drug-Shock group 21.2% of patients converted with the infusion. There were no statistically significant differences for time to conversion (84.2 vs 97.6 minutes), total ED length of stay (9.4 vs 7.5 hours), disposition home (100% vs 95.3%), and stroke within 14 days (0 vs 0). Premature discontinuation of infusion (usually for transient hypotension) was more common in the Drug-Shock group (9.1% vs 0.0%) but there were no serious adverse events. Conclusion: Both the Drug-Shock and Shock Only strategies were highly effective and safe in allowing AAFL patients to go home in sinus rhythm. IV procainamide alone was effective in only one fifth of patients, much less than for acute AF.
LO15: Paramedic and allied health professional interventions at long-term care facilities to reduce emergency department visits: systematic review
Authors: Leduc S. , Cantor Z. , Kelly P. , Thiruganasambandamoorthy V. , Wells G. , Vaillancourt C.
Published: May 2020

Introduction: Emergency department (ED) crowding, long waits for care, and paramedic offload delay are of increasing concern. Older adults living in long-term care (LTC) are more likely to utilize the ED and are vulnerable to adverse events. We sought to identify existing programs that seek to avoid ED visits from LTC facilities where allied health professionals are the primary providers of the intervention and, to evaluate their efficacy and safety. Methods: We completed this systematic review based on a protocol we published apriori and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. Two investigators independently selected studies and extracted data using a piloted standardized form and evaluated the risk of bias of included studies. We report a narrative synthesis grouped by intervention categories. Results: We reviewed 11,176 abstracts and included 22 studies. Most studies were observational and few assessed patient safety. We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Of the 13 studies that reported ED visits, all (100%) reported a decrease, and of the 16/17 that reported hospitalization, 94.1% reported a decrease. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. When measured, studies reported decreased hospital length of stay, more time spent with patients by allied health professionals and cost savings. Conclusion: We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. Many identified programs focused on improved primary care for patients. Interventions addressing acute care issues such as those provided by community paramedics, patient preferences, and quality of life indicators all deserve more study.
LO19: AED on the fly: A drone delivery feasibility study for rural and remote out-of-hospital cardiac arrest
Authors: Drennan I. , Cheskes S. , Snobelen P. , Nolan M. , Chan T. , McLeod S. , Dainty K. , Vaillancourt C. , Brooks S.
Published: May 2020

Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.
LO25: Characteristics of frequent users of emergency departments in Alberta and Ontario, Canada: an administrative data study
Authors: Rosychuk R. , Chen A. , Fielding S. , Hu X. , McLane P. , McRae A. , Ospina M.
Published: May 2020

Introduction: Frequent users to emergency departments (EDs) are a diverse group of patients with a disproportionate number of ED presentations. This study aimed to compare sociodemographic and clinical characteristics of adult high system users (HSUs) and control groups in two provinces. Methods: Cohorts of HSUs were created for Alberta and Ontario by identifying the patients with the top 10% of ED presentations in the National Ambulatory Care Reporting System during April 2015 to March 2016. Random samples of patients not in the HSU groups were selected in each province as controls (4:1 ratio). Sociodemographic and presentation data (e.g., Canadian Triage and Acuity Scale [CTAS], disposition) were extracted and compared using separate logistic regression models. Results: In Alberta, 101,250 HSU patients made 686,918 ED presentations (median [med] = 5 interquartile range [IQR] 4,7 presentations per patient), compared with 401,923 controls who made 560,765 ED presentations (med = 1 IQR 1,2 per patient). HSUs were more likely to be female (odds ratio (OR) = 1.20 95% confidence interval (CI) 1.18,1.22), older (OR = 1.03 per 5y 95%CI 1.03,1.03), live closer to hospital (OR = 1.02 per 100km 95%CI 1.00,1.03), and be from the lowest income quintile (OR = 1.39 95%CI 1.37,1.42) than controls. In Ontario, 478,424 HSUs made 2,222,487 ED presentations (med = 4 IQR 3,5 per patient) and 1,714,037 controls made 2,114,070 ED presentations (med = 1 IQR 1,1 per patient). Ontario HSUs were also more likely to be female (OR = 1.13 95%CI 1.12,1.14), older (OR = 1.03 per 5y 95%CI 1.03,1.03), and from the lowest income quintile (OR = 1.41 95%CI 1.40,1.42) than controls, but were less likely to live closer to hospital (OR = 0.93 per 100km 95%CI 0.92, 0.93). Higher acuity was seen in Ontario (CTAS 1/2 vs. others OR = 1.05 95%CI 1.04,1.06) but not for Alberta (CTAS 1/2 vs others OR = 0.75, 95%CI 0.74,0.76). Discharges were less likely in the HSUs compared to controls (Alberta OR = 0.89 95%CI 0.88,0,90; Ontario OR = 0.65 95%CI 0.65,0.66). HSUs were more likely to leave without being seen (Alberta OR = 1.10 95%CI 1.07,1.13; Ontario OR = 1.37 95%CI 1.35,1.40) and against medical advice (Alberta OR = 1.47 95%CI 1.41,1.53; Ontario OR = 1.67 95%CI 1.63,1.71). Conclusion: HSUs were more likely to be female, older, and poorer than controls. Ontario HSUs had higher acuity than the other groups. Disposition differed for HSUs and controls. Further study is required to identify ways to safely reduce ED utilization by HSUs.
LO33: Sharing and teaching electrocardiograms to minimize infarction
Authors: McLaren J. , Taher A. , Chartier L.
Published: May 2020

Background: Every 30-minute delay to ST-Elevation Myocardial Infarction (STEMI) reperfusion increases one-year mortality by 7.5%. A local audit found that the third of patient electrocardiograms (ECGs) not initially meeting classic STEMI criteria had an ECG-to-Activation (ETA) time of over 90 minutes, more than five times that of classic STEMIs. However, three quarters of “STEMI negative” ECGs met STEMI-equivalent patterns or rules for subtle occlusion, uncovering an opportunity for improvement. Aim Statement: We aimed to reduce ETA time, from initial emergency department (ED) ECG to activation of the cath lab, for patients whose ECGs did not meet classic STEMI criteria, by 30 minutes within one year (i.e. by Dec 2019). Measures & Design: We reviewed all ED Code STEMIs over a 35-month pre-intervention period. Root Cause analyses, including Ishikawa diagram and Pareto chart, led to our Plan-Do-Study-Act cycles: 1) a survey to engage our team; 2) a Grand Rounds presentation as an educational strategy; and 3) weekly web-based feedback to all ED physicians on STEMI-equivalents and subtle occlusions, using recent local cases. Our outcome measures were ETA times, stratified by ECGs not initially meeting STEMI criteria (primary) and those that did (secondary). Our process measures were the number of website visits and page views. Our balancing measure was the proportion of Code STEMIs without culprit lesion. We used Statistical Process Control (SPC) charts with usual special cause variation rules. Evaluation/Results: ETA time for the 37.5% of 56 ECGs that did not meet classic STEMI criteria decreased from 97.5 to 53.7 minutes (min), a 43.8-min absolute decrease (p = 0.037), while those meeting STEMI criteria remained the same (16.5 to 18.2min, p = 0.75). SPC charts did not show special cause variation. There were 2,634 page views (65.9/week) and 1,092 visits (27.3/week), in a group of 80 physicians—i.e. a third of the group each week. There was no change in Code STEMIs without culprit lesions (28.0 % to 23.3%, p = 0.41). Discussion/Impact: We reduced ETA time by 43.8min for the one third of patients with culprit lesions not initially meeting classic STEMI criteria, a magnitude associated with mortality impact. To do so, we used a multi-modal educational strategy including a novel web-based feedback approach to all ED physicians. Local feedback and education on this challenging-to-diagnose subgroup, guided by ETA time as a quality metric, could be replicated in other centres.
CAPTURING THE WORLD IN WORDS: LATER MOHIST HERMENEUTIC THEORIES ON LANGUAGE AND DISPUTATION
Authors: Brindley Erica F.
Published: May 2020

This essay examines some key statements in the Later Mohist treatises to gain a sense of their views on language and disputation (bian辯). I first show that the Later Mohists viewed disputation as an exercise in familiarizing oneself with patterns of language use and the verification of truth-claims in the phenomenal world. I then demonstrate that such an activity helps one attain one of the Mohists’ highest goals: the clarification of ethical imperatives about how to behave, as expressed through Heaven for all people. This claim ultimately links Early and Later Mohist ethical concerns and offers a religious explanation for Later Mohist involvement and interest in disputation. Lastly, I frame these writings from within a culture of debate about language in Early China—a culture which, for example, yielded not only Mohist views concerning the necessary correlation between language and reality, but also Confucian formulations on the rectification of names, and a Zhuangzian insistence on the emptiness of sayings.
A new terrestrial trace fossil Feoichnus martini n. isp. from the Upper Cretaceous Two Medicine Formation (USA)
Authors: Panascí Giulio , Varricchio David J.
Published: May 2020

A new trace fossil, Feoichnus martini new ichnospecies, from the Two Medicine Formation is here described. This ichnotaxon is reported from the upper Campanian deposits of the Egg Mountain locality (Montana) and consists of a hemispherical to hemiellipsoidal structure with a truncated upper edge, and a regular, rounded lower edge marked by a lined border composed of stained layers. The trace maker likely impregnated the border using organic fluids. The simple lined wall observed in F. martini n. isp. suggests that the structure was produced by an invertebrate soil-dwelling organism, likely an insect. Specimens are preserved as casts in calcitic Inseptisols alongside an abundant vertebrate fossil record composed by dinosaurian and nondinosaurian fossil remains, dinosaur eggs and nest structures, and pervasive insect bioturbation. Feoichnus martini n. isp. represents an additional, minor component of the impoverished Celliforma ichnofacies reported at Egg Mountain and expands the paleogeographical distribution of the ichnogenus Feoichnus Krause et al., 2008 to the Upper Cretaceous deposits of Montana, USA.

UUID: http://zoobank.org/7c1a5026-7f27-4f12-a9fb-1eb8daa93baf
Furness’s First Farmers: Evidence of Early Neolithic Settlement and Dairying in Cumbria
Authors: Robinson Gav , Town Matthew , Ballin Torben Bjarke , Clarke Ann , Dunne Julie , Evershed Richard P. , Gardiner Lynne F , Gibson Alex , Russ Hannah
Published: May 2020

In 2015, excavations at Stainton Quarry, Furness, Cumbria, recovered remains that provide a unique insight into Early Neolithic farming in the vicinity. Five pits, a post-hole, and deposits within a tree-throw and three crevices in a limestone outcrop were investigated. The latter deposits yielded potentially the largest assemblage of Carinated Bowl fragments yet recovered in Cumbria. Lipid analysis identified dairy fats within nine of these sherds. This was consistent with previous larger studies but represents the first evidence that dairying was an important component of Early Neolithic subsistence strategies in Cumbria. In addition, two deliberately broken polished stone axes, an Arran pitchstone core, a small number of flint tools and debitage, and a tuff flake were retrieved. The site also produced moderate amounts of charred grain, hazelnut shell, charcoal, and burnt bone. Most of the charred grain came from an Early Neolithic pit and potentially comprises the largest assemblage of such material recovered from Cumbria to date. Radiocarbon dating indicated activity sometime during the 40th–35th centuries calbcas well as an earlier presence during the 46th–45th centuries. Later activity during the Chalcolithic and the Early Bronze Age was also demonstrated. The dense concentration of material and the fragmentary and abraded nature of the pottery suggested redeposition from an above-ground midden. Furthermore, the data recovered during the investigation has wider implications regarding the nature and use of the surrounding landscape during the Early Neolithic and suggests higher levels of settlement permanence, greater reliance on domesticated resources, and a possible different topographical focus for settlement than currently proposed.
AN IMPROVED LOWER BOUND FOR THE CRITICAL PARAMETER OF STAVSKAYA’S PROCESS
Authors: RAMOS ALEX D. , SOUSA CALITÉIA S. , RODRIGUEZ PABLO M. , CADAVID PAULA
Published: May 2020

We consider Stavskaya’s process, which is a two-state probabilistic cellular automaton defined on a one-dimensional lattice. The state of any vertex depends only on itself and on the state of its right-adjacent neighbour. This process was one of the first multicomponent systems with local interaction for which the existence of a kind of phase transition has been rigorously proved. However, the exact localisation of its critical value remains as an open problem. We provide a new lower bound for the critical value.
Multilevel Analysis with Few Clusters: Improving Likelihood-Based Methods to Provide Unbiased Estimates and Accurate Inference
Authors: Elff Martin , Heisig Jan Paul , Schaeffer Merlin , Shikano Susumu
Published: May 2020

Quantitative comparative social scientists have long worried about the performance of multilevel models when the number of upper-level units is small. Adding to these concerns, an influential Monte Carlo study by Stegmueller (2013) suggests that standard maximum-likelihood (ML) methods yield biased point estimates and severely anti-conservative inference with few upper-level units. In this article, the authors seek to rectify this negative assessment. First, they show that ML estimators of coefficients are unbiased in linear multilevel models. The apparent bias in coefficient estimates found by Stegmueller can be attributed to Monte Carlo Error and a flaw in the design of his simulation study. Secondly, they demonstrate how inferential problems can be overcome by usingrestrictedML estimators for variance parameters and at-distribution with appropriate degrees of freedom for statistical inference. Thus, accurate multilevel analysis is possible within the framework that most practitioners are familiar with, even if there are only a few upper-level units.