bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.
PL01: Creation of a risk scoring system for emergency department patients with acute heart failure
Authors: Stiell I. , Perry J. , Clement C. , Sibley S. , McRae A. , Rowe B. , Borgundvaag B. , McLeod S. , Mielniczuk L. , Dreyer J. , Yan J. , Brown E. , Brinkhurst J. , Nemnom M. , Taljaard M. 
Published: May 2020

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

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

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

Introduction: The Canadian Syncope Risk Score (CSRS) is a validated risk tool developed using the best practices of conventional biostatistics, for predicting 30-day serious adverse events (SAE) after an Emergency Department (ED) visit for syncope. We sought to improve on the prediction ability of the CSRS and compared it to physician judgement using artificial intelligence (AI) research with modern machine learning (ML) methods. Methods: We used the prospective multicenter cohort data collected for the CSRS derivation and validation at 11 EDs across Canada over an 8-year period. The same 43 candidate variables considered for CSRS development were used to train and validate the four classes of ML models to predict 30-day SAE (death, arrhythmias, MI, structural heart disease, pulmonary embolism, hemorrhage) after ED disposition. Physician judgement was modeled using the two variables, referral for consultation and hospitalization. We compared the area under the curve (AUC) for the three models. Results: The proportion of patients who suffered 30-day SAE in the derivation cohort (N = 4030) was 3.6% and in validation phase (N = 2290) was 3.4%. Characteristics of the both cohorts were similar with no shift. The best performing ML model, a gradient boosting tree-based model used all 43 variables as predictors as opposed to the 9 final CSRS predictors. The AUC for the three models on the validation data were: best ML model 0.91 (95% CI 0.87–0.93), CSRS 0.87 (95% CI 0.83–0.90) and physician judgment 0.79 (95% CI 0.74 - 0.84). The most important predictors in the ML model were the same as the CSRS predictors. Conclusion: A ML model developed using AI method for risk-stratification of ED syncope performed with slightly better discrimination ability though not significantly different when compared to the CSRS. Both the ML model and the CSRS were better predictors of poor outcomes after syncope than physician judgement. ML models can perform with similar discrimination abilities when compared to traditional statistical models and outperform physician judgement given their ability to use all candidate variables.
LO26: The mean abnormal response rates of laboratory tests ordered in the emergency department: shooting percentage insights from a multicentre study
Authors: Enwere E. , Wang D. , Guo M. , Naugler C. , Lang E. 
Published: May 2020

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

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

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