bluuebunny/crossref_metadata_2025_split huggingface dataset:
P049: Goals of care discussion in the emergency department: is it possible
Authors: Péloquin F. , Marmen É. , Gélinas V. , Plaisance A. , Archambault P. 
Published: May 2020

Introduction: The Institut national d'excellence en santé et en services sociaux in Quebec published guidelines suggesting that emergency physicians should establish emergency department (ED) patients’ goals of care when appropriate. The objective of this study was to explore emergency physicians’ opinions about leading goals of care discussion (GCD) in their daily practice. Methods: This study used a qualitative design based on the Normalisation Process Theory (NPT); a middle-range theory used to explain the sustainability of implementing complex healthcare interventions. It was conducted in a single academic ED in Lévis, Québec. We planned to recruit a minimal convenience sample of 10 participants. Between April and May 2018, we conducted semi-structured interviews and transcribed the audio records verbatims. Deductive thematic analysis based on the NPT was conducted using Nvivo 12.0. Two authors codified the content of each interview under the four NPT macro-level constructs: coherence, cognitive participation, collective action and reflexive monitoring. A kappa score was calculated to measure the coding inter-rater reliability. Results: We interviewed 10 ED physicians (50 % women; 60% certified by the College of Family Physicians of Canada (Emergency Medicine)). No new ideas emerged after the 9th interview. Our thematic analysis identified 13 themes. Inter-rater reliability of coding was substantial (kappa = 0.72). The coherence construct contained the following themes: common concept of interpersonal communication, efficiency of care and anxiety generated by the discussion, the identification of an acute deterioration leading to the GCD, coming together of clinician, patient and family, and the importance of knowing patients’ goals of care before medical handover. The cognitive participation construct involved the following themes: lack of training on the new goals of care form and availability of reminders to promote the recommendation. One theme characterized the collective action construct: heterogeneous prioritization for leading GCD. The reflexive monitoring construct contained 4 themes: need to take action before patients consult in the ED, need to develop education programs, need for legislation and the impossibility of systematic GCD for all patients. Conclusion: Goals of care discussion is possible and essential with selected patients in the ED. Nevertheless, policy-making efforts remain necessary to ensure the systematization of the recommendation.
P054: Delay in decision to transfer time for critically ill patients transported by air ambulance in Ontario
Authors: Myers V. , Nolan B. 
Published: May 2020

Introduction: Delays in definitive management of critically ill patients are known to drive poor clinical outcomes. A scarcely studied time period in interfacility transfer is the time between initial patient presentation and the decision to transfer. This study seeks to identify patient, environmental and institutional characteristics associated with delays in decision to transfer critically ill patients by air ambulance to a tertiary care centre. Methods: Patients >18 years old who underwent emergent air ambulance interfacility transport to a tertiary care centre were included. Patient records were located in a provincial air ambulance database. The primary exposure variable was time from patient presentation to initial call to facilitate transfer. Patient, environmental and institutional characteristics were identified using stepwise variable selection at a significance of 0.1. These characteristics were then explored using quantile regression to identify significant factors associated with delay in transport initiation. Results: A total of 11231 patients were included in the analysis. There were 5009 females (44.60%) and 6222 males (55.4%). The median age of patients was 57. The median time to initiate the transfer was 3.05 hours. The variables identified with stepwise selection were gender, category of illness, heart rate, systolic blood pressure, Glasgow coma scale, vasopressor usage, blood product usage, time of day, and type of sending site. The following factors were significantly (p < 0.05) associated with an increase in time to initiate transfer compared to the reference category at the 90th centile of time: cardiac illness (+1.45h), gastrointestinal illness (+3.27h), respiratory illness (+4.90h), sepsis (+3.03h), vasopressors (+2.31h), and an evening hour of transport (+3.67h). The following factors were significantly (p < 0.05) associated with a decrease in time to initiate transfer compared to the reference category at the 90th centile of time: neurologic illness (-1.45h), obstetrical illness (-1.56h), trauma (-3.14h), GCS <8 (-0.98h), blood transfusion (-1.47h), and sending site being a community hospital >100 beds (-2.26h), <100 beds (-4.71h), or nursing station (-10.02h). Conclusion: Time to initiate transfer represents a significant window in a patient's transport journey. In looking at the predictors of early or late initiation of transfers, these findings provide education and quality improvement opportunities in decreasing time to definitive care in critically ill populations.
P057: Impact of a clinical pathway for the treatment of acute asthma in the emergency department
Authors: Messier F. , Deshaies J. , Breault G. 
Published: May 2020

Introduction: In Canada, acute asthma is a common cause of emergency department (ED) attendance and its treatment is affected by ED overcrowding and increasing wait times. Literature suggests that a clinical pathway (CP) for the treatment of acute asthma can increase the use of medical therapy, reduce hospital admission rates and decrease associated costs. However, only few have looked at the effect on ED length of stay (ED LOS) when such a CP is initiated by triage nurse/respiratory therapist among adults. In this optic, an asthma CP was launched on Feb. 2016 at Centre Hospitalier Universitaire de Sherbrooke (QC) and included medical directives allowing triage nurse and respiratory therapist initiation of treatment. Methods: The objectives are to determine the effect of an ED nurse/respiratory therapist-initiated asthma CP on (1) ED LOS, (2) time-to-treatment (beta-agonist, corticosteroids), time-to-MD and other secondary outcomes. This was a retrospective before-after study. Adults presenting to the ED before and after CP implementation with a final diagnosis of asthma or asthma exacerbation were eligible. The groups A (before implementation) and B (after implementation) were compared for ED LOS. Three subgroups of 50 patients were generated and compared for outcomes: A1 (before implementation), B1 (after implementation without CP) and B2 (after implementation with CP). All five groups were controlled for triage level and sex. Results: In total, 1086 patients were included; 543 before implementation (Mar. 2011 – Feb. 2016) and 543 after (Feb. 2016 – Jun. 2019), of whom 14% (N = 77) were treated by CP. The average ED LOS was similar (10.36h vs 10.65h; (p = 0,31)) in group A and in group B. In groups A1, B1 and B2, the median ED LOS were respectively 6.00, 6.84, 4.80; these differences were not statistically significant. The average time-to-treatment for beta-agonist in A1, B1 and B2 was respectively 148, 180 and 50 mins; the differences between B2 and A1 and between B2 and B1 were both statistically significant (p < 0,05). Conclusion: Although this study indicates a low compliance to the CP, it shows that time-to-treatment can be reduced. It didn't demonstrate any statistically significant decrease in ED LOS, most likely due to low number of patients and non-normal distribution, but the 1.2h shorter could be a major advantage if it proves true. Further studies are essential to understand facilitators and alleviate the barriers in anticipation of a multi-centric implementation.
P059: Characteristics of older adults attending the emergency department for suicidal thoughts or voluntary intoxication: a multicenter retrospective cohort study
Authors: Mercier E. , Boulet S. , Gagnon A. , Nadeau A. , Mowbray F. 
Published: May 2020

Introduction: Suicidal thoughts and self-harm are disproportionately prevalent among older adults but are frequently overlooked by emergency physicians. Objective: This study aims to explore the characteristics of older adults visiting the ED for suicidal thoughts or voluntary intoxications. Methods: All older adults (□ 65 years old) who visited one of the five CHU de Quebec’ EDs in 2016 were eligible. The medical charts of patients who reported suicidal thoughts or intoxication in triage or received a relevant discharge diagnosis were reviewed. Involuntary intoxications were excluded. Descriptive statistics were used to present the results. Results: Results: A total of 478 ED visits were identified, of which 332 ED visits (n= 279 patients) were included. The mean age of the ED cohort was 72.6 (standard deviation 6.8) years old and 41.6% were female. Mood disorders (41.2%) and alcoholism (40.5%) were common. Most included patients had a diagnosis of voluntary intoxication (73.2%), including two suicides (0.6%). Following 109 ED visits (30.0%), patients were referred for a mental health assessment. Half of all ED visits resulted in a discharge by the emergency physician (50.0%), while 27.4% were admitted for in-patient care. In the subsequent year (2017), 38.4% returned to the ED for suicidal ideations or self-harm of which 7.9% attended the ED □ 5 times. Conclusion: ED visits for suicidal thoughts and voluntary intoxication in older adults are more common among men with known mood disorders or alcoholism. Referral for a mental health assessment is inconsistent. ED-initiated interventions designed for this population are needed.
P071: Artificial intelligence in emergency medicine: A scoping review
Authors: Kirubarajan A. , Taher A. , Khan S. , Masood S. 
Published: May 2020

Introduction: The study of artificial intelligence (AI) in medicine has become increasingly popular over the last decade. The emergency department (ED) is uniquely situated to benefit from AI due to its power of diagnostic prediction, and its ability to continuously improve with time. However, there is a lack of understanding of the breadth and scope of AI applications in emergency medicine, and evidence supporting its use. Methods: Our scoping review was completed according to PRISMA-ScR guidelines and was published a priori on Open Science Forum. We systematically searched databases (Medline-OVID, EMBASE, CINAHL, and IEEE) for AI interventions relevant to the ED. Study selection and data extraction was performed independently by two investigators. We categorized studies based on type of AI model used, location of intervention, clinical focus, intervention sub-type, and type of comparator. Results: Of the 1483 original database citations, a total of 181 studies were included in the scoping review. Inter-rater reliability for study screening for titles and abstracts was 89.1%, and for full-text review was 77.8%. Overall, we found that 44 (24.3%) studies utilized supervised learning, 63 (34.8%) studies evaluated unsupervised learning, and 13 (7.2%) studies utilized natural language processing. 17 (9.4%) studies were conducted in the pre-hospital environment, with the remainder occurring either in the ED or the trauma bay. The majority of interventions centered around prediction (n = 73, 40.3%). 48 studies (25.5%) analyzed AI interventions for diagnosis. 23 (12.7%) interventions focused on diagnostic imaging. 89 (49.2%) studies did not have a comparator to their AI intervention. 63 (34.8%) studies used statistical models as a comparator, 19 (10.5%) of which were clinical decision making tools. 15 (8.3%) studies used humans as comparators, with 12 of the 15 (80%) studies showing superiority in favour of the AI intervention when compared to a human. Conclusion: AI-related research is rapidly increasing in emergency medicine. AI interventions are heterogeneous in both purpose and design, but primarily focus on predictive modeling. Most studies do not involve a human comparator and lack information on patient-oriented outcomes. While some studies show promising results for AI-based interventions, there remains uncertainty regarding their superiority over standard practice, and further research is needed prior to clinical implementation.
P074: Emergency department utilization and outcomes for patients with early pregnancy complications
Authors: Glicksman R. , Little D. , Thompson C. , McLeod S. , Varner C. 
Published: May 2020

Introduction: Affecting roughly 1 in 5 pregnancies, early pregnancy loss is a common experience for reproductive-aged women. In Canada, most women do not establish care with an obstetrical provider until the second trimester of pregnancy. Consequently, pregnant patients experiencing symptoms of early pregnancy loss frequently access care in the emergency department (ED). The objective of this study was to describe the resource utilization and outcomes of women presenting to two Ontario EDs for early pregnancy loss or threatened early pregnancy loss. Methods: This was a retrospective cohort study of pregnant (≤20 weeks), adult (≥18 years) women in two EDs (one community hospital with 110,000 annual ED visits; one academic hospital with 65,000 annual ED visits) between January 2010 and December 2017. Patients were identified by diagnostic codes indicating early pregnancy loss or threatened early pregnancy loss. Results: A total of 16,091 patients were included, with a mean (SD) age of 32.8 (5.6) years. Patients had a total of 22,410 ED visits for early pregnancy complications, accounting for 1.6% of the EDs’ combined visits during the study period. Threatened abortion (n = 11,265, 50.3%) was the most common ED diagnosis, followed by spontaneous abortion (n = 5,652, 25.2%), ectopic pregnancy (n = 3,242, 14.5%), missed abortion (n = 1,541, 6.9%), and other diagnoses (n = 710, 3.2%). 8,000 (44.8%) patients had a radiologist-interpreted ultrasound performed during the initial ED visit. Median (IQR) ED length of stay was 3.4 (2.3 to 5.1) hours. There were 4,561 (25.6%) return ED visits within 30 days, of which 2,317 (50.8%) occurred less than 24 hours of index visit, and 481 (10.6%) were for scheduled, next day ultrasound. The total number of hospital admissions was 1,793 (8.0%), and the majority were for ectopic pregnancy (n = 1,052, 58.7%). Of admitted patients, 1,320 (73.6%) underwent surgical interventions related to early pregnancy. There were 474 (10.4%) patients admitted to hospital during return ED visits. Conclusion: Pregnant patients experiencing symptoms of early pregnancy loss in the ED frequently had radiologist-interpreted US and low rates of hospital admission, yet had high rates of return ED visits. This study highlights the heavy reliance on Ontario EDs to care for patients experiencing complications of early pregnancy.
P093: Evaluating factors related to effective interpersonal communication during mandatory paramedic patches
Authors: Kelton D. , Doran S. , Davis M. , Van Aarsen K. , Momic J. 
Published: May 2020

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. Many factors contribute to success or failure of effective interpersonal communication during a patch call. The aim of this study was to examine areas of potential improvement in communication between paramedics and physicians during the patch call. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Pre-specified time intervals, clinical factors, specific patch requests and resulting orders from the BHP to the paramedics were extracted. Differences between groups were compared using t-tests. Results: 214 records were initially identified and screened. 91 ACRs and audio patch records were included in the analysis. 51/91 (56%) of patch order requests for interventions were granted by the BHP. Clarification of information provided by the paramedic or reframing of the paramedic's request was required less often, but not statistically significant, in calls ultimately resulting in granted requests versus those that were not granted (mean 1.4 versus 1.7, Δ-0.28; 95% CI -0.75-0.18 p = 0.64). The mean time from first contact with the BHP to statement of the request was similar in patches where the request was granted and not granted (44.9 versus 46.3, Δ-1.4; 95% CI -12.9-10.2, p = 0.49). Conclusion: The communication between BHPs and paramedics is an important and under-investigated component of prehospital emergency care. This retrospective review presents some novel targets for further research and potential education in patch communication to improve efficiency and quality of prehospital care for patients.
P101: Seasonal variations in modes of presentation in ST elevation myocardial infarction
Authors: Forestell B. , Hewitt M. , Mondoux S. 
Published: May 2020

Introduction: For patients with ST-elevation myocardial infarction (STEMI), time is myocardium. The sooner STEMI patients receive a definitive intervention, the better their outcomes. The first point of contact with the healthcare system for STEMI patients is either via Emergency Medical Services (EMS), or self-transportation to an Emergency Department (ED). Despite a reduced time to definitive intervention, STEMI patients who use EMS have increased mortality compared to those who self-transport. In an effort to optimize STEMI care pathways, we characterized variations in modes of presentation of STEMI patients in our region. Methods: This study used a retrospective cohort design from a regional STEMI registry. Patients presenting to Hamilton Health Sciences between January 1, 2016, and December 31, 2018 meeting STEMI criteria were included in our analyses. Self-transport patients were analyzed from two academic EDs in Hamilton, Ontario. One hospital was PCI capable and the other, non-PCI capable. Patients transferred from other health regions were excluded from our analyses. Dichotomous variables were compared using χ2 tests. Group means were compared using the Student t-test. Results: Eight hundred and seventy-one patients were included in the analysis, including 675 EMS users, and 196 self-transporting to EDs. Patients self-transporting to EDs were younger (61.5 v. 64.6 y, p < 0.002) and more often male (82.6 v. 69.2%, p < 0.0002) compared to EMS users. There was a non-significant trend towards an increased rate of all STEMI patients self-transporting in the summer months compared to the winter (63 of 215 in summer v. 41 of 185 in winter, 29.3 v. 22.2%, p = 0.10). Comparative analysis between both hospitals yielded an increased rate of self-transportation to the PCI-capable hospital in the summer months compared to winter (46 v. 28, 23.2 v. 16.3%, p = 0.09), but not the other hospital (18 v. 13, 10.6 v. 8.3%, p = 0.57). The majority of self-transporting patients came from postal codes bordering each hospital, and the different rates of self-transportation between hospitals were not associated with recent specialist follow up at those sites. Conclusion: Seasonal trends in modes of presentation in STEMI patients may present an opportunity to optimize STEMI care pathways through resource utilization and patient education. A larger dataset and possible multicenter analysis should be done to determine if significance is obtained with larger sample size.
P118: Impact des bêtabloquants pour les patients souffrant d'un arrêt cardiorespiratoire avec un rythme initial défibrillable : une revue systématique et méta-analyse
Authors: Cournoyer A. , Soucy-Legault J. , Frégeau A. , Iseppon M. , Iseppon A. , Lessard J. , Huard V. , Morris J. , Chauny J. , Marquis M. , Paquet J. , Daoust R. 
Published: May 2020

Introduction: Malgré les progrès au niveau des soins de réanimation lors des dernières années, le pronostic des patients souffrant d'un arrêt cardiorespiratoire (ACR) demeure abyssal et aucun médicament ne semble influencer leur devenir au long cours. Cependant, les résultats de quelques études évaluant l'impact des bêtabloqueurs chez cette population s'avèrent cependant très encourageants. L'objectif de cette revue systématique, est d’évaluer l’évidence disponible quant à l'impact des bêtabloqueurs sur le devenir des patients traités pour un ACR dont le rythme initial est défibrillable. Methods: La présente revue systématique a été préalablement enregistrée sur Prospero (CRD42018105453). Les moteurs de recherche Medline, Embase et CENTRAL ont été fouillés de leur création jusqu'au 17 octobre 2018. La recherche de littérature grise s'est faite via Web of Science et Google Scholar. Les références de tous les articles inclus ainsi que des méta-analyses existantes sur le sujet ont également été révisées. Tous les types de devis ont été considérés, sauf les études de cas et les séries de cas. Les études devaient inclure des adultes (16 ans et plus) en ACR dont le rythme initial était défibrillable, dont une partie avait reçu un médicament bêtabloquants par voie intraveineuse pendant leur ACR et l'autre un traitement standard, et présenter une mesure de résultat centrée sur le patient (retour de circulation spontanée [RCS], survie ou bon devenir neurologique). La qualité des articles a été évaluée à l'aide du ‘Newcastle Ottawa scale’. Results: Deux études observationnelles rétrospectives, menées auprès d'un total de 66 patients, ont été incluses. Il y avait une association positive entre l'administration de bêtabloquants et l'occurrence d'un RCS (rapport de cotes [RC] = 5.76 [intervalle de confiance {IC} à 95% = 1.79-18.52], p = 0.003), ainsi qu'avec la présence d'un bon devenir neurologique (RC = 4.42 [IC95% = 1.05 - 18.56], p = 0.04). Une telle association n'a cependant pas été observée par rapport à la survie au congé hospitalier. Conclusion: L'administration de bêtabloquants semble associé à un meilleur devenir chez les patients en ACR avec un rythme initial défibrillable. Étant donné la nature du devis de ces études et leur petite taille, une étude prospective de qualité serait nécessaire afin de déterminer l'efficacité de cette classe de médicament et de faire une recommandation forte à ce sujet.