bluuebunny/crossref_metadata_2025_split huggingface dataset:
MP16: Oral case presentation: evaluation of a novel curriculum and development of a competency-based assessment tool in Emergency Medicine
Authors: Wawrykow T. , McColl T. , Velji A. , Chan M. 
Published: May 2020

Introduction: The oral case presentation is recognized as a core educational and patient care activity but has not been well studied in the emergency setting. The objectives of this study are: 1) to develop a competency-based assessment tool to formally evaluate the emergency medicine oral case presentation (EM-OCP) competency of medical students and ‘transition to discipline’ residents, and 2) to develop, implement and evaluate a curriculum to enhance oral case presentation (OCP) communication skills in the emergency medicine (EM) setting. Methods: Using data from a literature review, a Canadian Association of Emergency Physicians national survey, and local focus groups, the authors designed an OCP framework, blended learning curriculum, and EM-OCP assessment tool. Ninety-six clerkship students were randomly assigned to receive either the control, the standard clerkship curriculum, or intervention, the blended learning curriculum. At the beginning of their emergency medicine rotation, learners completed a pre-test using a standardized patient (SP) case to assess their baseline OCP skills. The intervention group then completed the EM-OCP curriculum. All students completed post-tests with a different SP at the end of the six-week EM rotation. Audio-recordings of pre and post-tests were evaluated using the assessment tool by two blinded evaluators. Results: Using the Kruskal-Wallis test, all students demonstrated improvement in EM-OCP skills between their pre-test and post-test, however, those who received the blended learning curriculum showed significantly greater improvement in synthesis of information (p = 0.044), management (p = 0.006) and overall entrustment decision score (p = 0.000). Conclusion: Implementation of a novel EM-OCP curriculum resulted in more effective communication and higher entrustment scores. This curriculum could improve OCP performance not only in emergency medicine settings but also across specialties where medical students and residents must manage critical patients.
MP39: Emergency department triage redesign: can elements designed to improve department flow reduce door-to-ECG times in self-presenting ED patients suspected of myocardial infarction?
Authors: Hewitt M. , Forestell B. , Mondoux S. 
Published: May 2020

Introduction: ST-Elevation Myocardial Infarction (STEMI) represents irreversible necrosis of myocardial tissue. Prompt time-to-reperfusion in these patients is paramount in reducing morbidity and mortality. This concept, time-to-reperfusion, is the principle focus for improving STEMI care. Prioritizing diagnosis in patients with high-risk cardiac features through rapid electrocardiogram (ECG) is essential, with gold standard time-to-ECG benchmarked at 10-minutes. While substantial literature is established for pre-hospital ECG interventions, there is a paucity of intervention data for self-presenting patients. While evaluating these times within our department, we conducted a redesign of the triage process. These included nurses becoming the first contact and the addition of an extra triage nurse. These changes provided the opportunity to evaluate whether the redesign elements of the triage system meant to improve department flow could improve other patient-centered outcomes, namely time-to-ECG. Methods: The first fifty self-presenting patients designated as “cardiac chest pain” in the month preceding changes to the triage system were analyzed to create a baseline time-to-ECG value. Following the alteration to our triage system, three samples of the first 50 patient's time-to-ECG were collected at two, four and six months post-intervention and compared to pre-intervention via non-paired t-test. Data was further stratified into percentages of patients receiving an ECG within 10-minute intervals starting with 0-10 minutes. Proportions pre and post intervention were then compared using z-scores. Results: A baseline pre-intervention time-to-ECG value of 26.6 minutes was established. Average post-intervention time-to-ECG was significantly reduced at 15.6min with a mean difference of -11.0min ± 3.0 (95% CI -16.0 – (-5.0)). Interestingly, the proportion of ECGs performed under 20 minutes rose significantly from 58% to 81% (z=−3.2, p < 0.001) while the increase in proportion of ECGs performed under 10 minutes from 26% to 37% was not statistically significant (z=−1.4). Conclusion: The results of this analysis suggest that the addition of an extra triage nurse coupled with changing first point of ED contact from the business clerks to triage nurses significantly reduced mean time-to-ECG in self-presenting patients with chest pain deemed high risk for cardiac causes. Additionally, these changes significantly increased the proportion of ECGs performed within 20 minutes of ED arrival in these patients.
MP52: Effectiveness of an outpatient parenteral antibiotic therapy clinic for adults with non-purulent cellulitis
Authors: Mattice A. , Yip R. , Eagles D. , Rosenberg H. , Suh K. , Stiell I. , Yadav K. 
Published: May 2020

Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age >=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p < 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were <2% and adverse events were <5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.
MP57: Effect of grip strength measured in the emergency department on the risk of functional decline following a minor trauma in robust elderly: a pan-Canadian study
Authors: Hegg S. , Sirois M. , Carmichael P. , Perry J. , Lee J. , Daoust R. , Lang E. , Emond M. 
Published: May 2020

Introduction: The elderly (65 yo and more) increase in Canada is well documented along with a disproportionate use of Emergency Departments after a minor injury. These patients requires specific care given a 16% risk of functional decline following a visit to ED. To prevent functional decline, a multidimensional assessment of the elderly is recommended in the emergency department. Objective: To determine if ED grip strength can predict functional decline at 3 or 6 months post-injury. Methods: A multicentre prospective study in 5 ED across Canada was realized between 2013 and 16. Patients 65 years old and over, autonomous in daily living activities and consulting the emergency department for minor trauma were recruited 7 days a week. Clinical-demographic data, functional status, fear of falling, number of falls in the last month, grip strength measurement were collected in the ED. Functional decline (loss of at least points to functional status) was calculated at 3 and 6 months. Descriptive statistics and linear regression model with repeated measurements were used to determine if the grip strength was predictive of functional decline at 3 or 6 months. Results: 387 patient were recruited. Mean age was 74 ± 7 years old, 52% were male. XXX experienced a fall in the last month. The initial maximum grip strength was (24 ± 10 intervention vs. 28 ± 13 control; p ≤ 0.05). grip strength is associated with pre-injury functional status (p < 0.0001) and fear of falling (p = 0.0001) but does not predict 3 or 6 month functional decline. Conclusion: Given the strong association with fear of falling and functional status at initial ED evaluation, we recommend that grip strength measurement could be included in a multidisciplinary geriatric emergency department assessment as needed.
MP58: Have opioid prescription by emergency physicians changed significantly over five years?
Authors: Wei M. , Silva M. Da , Perry J. 
Published: May 2020

Introduction: It is believed by some that emergency physicians prescribe more opioids than required to manage patients’ pain, and this may contribute to opioid misuse. The objective of our study was to assess if there has been a change in opioid prescribing practices by emergency physicians over time for undifferentiated abdominal pain. Methods: A medical record review for adult patients presenting at two urban academic tertiary care emergency departments was conducted for two distinct time periods; the years of 2012 and 2017. The first 500 patients within each time period with a discharge diagnosis of “abdominal pain” or “abdominal pain not yet diagnosed” were included. Data were collected regarding analgesia received in the emergency department and opioid prescriptions written. Opioids were standardized into morphine equivalent doses to compare quantities of opioids prescribed. Analyses included t-test for continuous and chi-square for categorical data. Results: 1,000 patients were included in our study. The mean age was 42.0 years and 69.6% of patients were female. Comparing 2017 to 2012, there was a non-significant decrease in opioid prescriptions written for patients discharged directly by emergency physicians, from 17.8% to 14.4% (p = 0.14). Mean opioid quantities per prescription decreased from 130.4 milligrams of morphine equivalents per prescription to 98.9 milligrams per prescription (p = 0.002). 13.9% of opioid prescriptions in 2017 were for more than 3 days, which is a decrease from 28.1% in 2012. During the emergency department care, there was an increase in foundational analgesia use prior to initiating opioids from 17.6% to 26.8% (p = 0.001). There was also a decrease for within ED opioid analgesia use from 40.0% to 32.8% (p = 0.018). Conclusion: Opioid prescription rates did not change significantly during our study. However, physicians reduced the quantity of opioids per prescription and used less opioid analgesia in the emergency department for abdominal pain of undetermined etiology.
P012: Does physician burnout differ between urban and rural emergency medicine physicians? A comparison using the Maslach Burnout Inventory tool
Authors: Leigh R. , Van Aarsen K. , Foxcroft L. , Lim R. 
Published: May 2020

Introduction: Previous literature suggests that emergency medicine physicians experience high levels of work-related burnout. However, these results are drawn primarily from physicians working in large urban emergency departments. The aim of this study was to compare physician wellness between emergency medicine physicians working in urban versus rural settings. Methods: Emergency medicine physicians were recruited to complete a wellness survey from both urban and rural emergency medicine departments in Southwestern Ontario. The primary outcome measure of interest was physician burnout as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). This survey tool measures physician burnout in the three domains of emotional exhaustion, depersonalization, and personal accomplishment. Descriptive statistics, paired t-tests and Mann-Whitney U tests were used to analyze parametric and non-parametric burnout domain data respectively. Results: Surveys were completed by 67/99 (68%) and 22/66 (33%) of urban and rural emergency medicine physicians, respectively. An emotional exhaustion score ≥27 OR a depersonalization sub-score ≥10 was considered the threshold for burnout and was found in 71.4% (40/56) of urban physicians surveyed and 85.7% (18/21) (P = 0.20) of rural physicians. No statistically significant difference in mean emotional exhaustion, depersonalization, or personal accomplishment was noted between groups. Conclusion: High levels of burnout were noted amongst both urban and rural emergency medicine physicians. No statistically significant differences were noted between groups when compared on the Maslach Burnout Inventory survey tool. Despite many factors differentiating urban from rural practice, rural emergency doctors suffer similar rates of burnout. Thematic qualitative interviews exploring specific burnout factors may offer further insight into the drivers of physician burnout.
P015: Efficacy of the Brain Injury Guidelines for complicated mild traumatic brain injuries
Authors: Tourigny J. , Malo C. , Boucher V. , Blanchard P. , Chauny J. , Clark G. , Paquet V. , Fortier É. , Émond M. 
Published: May 2020

Introduction: The Brain Injury Guidelines (BIG) stratifies complicated mild traumatic brain injury (mTBI) patients into 3 groups to guide hospitalization, neurosurgical consultation and repeat head-CT. BIG-1 patients could be managed safely without neurosurgical consultation or transfer. Systematic transfer to neurotrauma centers provide few benefits to this subgroup leading to overtriage. Similarly, unnecessary clinical and radiological follow-ups utilize significant health-care resources. Objective: to validate the safety and efficacy of the BIG for complicated mTBIs. Methods: We performed a multicenter historical cohort study in 3 level-1 trauma centers in Quebec. Patients ≥16 years old assessed in the Emergency Department (ED) with complicated mTBI between 2014 and 2017 were included. Patients with penetrating trauma, cerebral aneurysm or tumor were excluded. Clinical, demographic and radiological data, BIG variables, TBI-related death and neurosurgical intervention were collected using a standardized form. A second reviewer assessed all ambiguous files. Descriptive statistics, over- and under-triage were calculated. Results: A total of 342 patients’ records were assessed. Mean age was 63 ± 20,7 and 236 (69 %) were male. Thirty-five patients were classified under BIG-1 (10.2%), 110 under BIG-2 (32.2%) and 197 under BIG-3 (57.6%). Twenty-six patients (7%) required neurosurgical intervention, all were BIG-3. 90% of TBI-related deaths occurred in BIG-3 and none were classified BIG-1. Among the 192 transfers (51%), 14 were classified under BIG-1 (7.3%) and should not have been transferred according to the guidelines and 50 under BIG-2 (26%). In addition, 40% of BIG-1 received a repeat head computed tomography, although not indicated. Similarly, 7 % of all patients had a neurosurgical consult even if not required. Projected implementation of BIG would lead to 47% of overtriage and 0.3% of undertriage. Conclusion: Our results suggest that the Brain Injury Guidelines could safely identify patients with negative outcomes and could lead to a safe and effective management of complicated mTBI. Applying these guidelines to our cohort could have resulted in significantly fewer repeat head CTs, neurosurgical consults and transfers to level 1 neurotrauma centers.
P034: Computed tomography rates for emergency department super-users
Authors: Savage D. , North R. , McKay G. , McMillan C. , Stonebridge R. , Piper B. , Jeffery A. , Ohle R. , VanderBurgh D. 
Published: May 2020

Introduction: Most emergency departments (ED) in Canada have a population of high frequency users that present to the ED on a regular basis. These patients are well described in the literature and typically defined by a frequency of 8-10 visits/year. In Thunder Bay, Ontario we have a significant population of patients that present more often that we have termed “super-users”. These patients often are typically from a vulnerable population with multiple co-morbidities and a high mortality rate. Although their risk for poor health outcomes is well recognized, both the chronicity and complexity of their symptoms often contributes to diagnostic dilemmas. The decision to order a computed tomography (CT) scan can be a difficult balance between ruling out life threatening diagnoses and exposing the patient to excessive radiation. Our objective was to describe how often these super-users of the ED received a CT scan and what types of imaging were completed. Methods: The Thunder Bay Regional Health Sciences Centre is a geographically isolated hospital in Northwestern Ontario with the next closest hospital based CT scanner greater than 300 km away. Based on previous literature and our preliminary scoping of the super-user group, we have identified a minimum of 25 visits as the threshold. A retrospective chart review was conducted for the year 2017 using our electronic medical record. Patient demographic data was collected along with the type and number of CT scans into a standardized collection tool. Results: Our preliminary results showed that our total population of super-users was 75 patients with an average of 32 visits to the ED per year. A total of 76% of the patients had a CT scan completed at least once. On average these patients have a CT during 10% of their visits with head CT comprising 50% of the imaging and abdominal/pelvis imaging comprising another 45%. For 20% of these super-users, they had CTs on 20% of their visits. From this population, only 10% of the patients had surgery in 2017 while 7% of visits required admission to hospital. The most common diagnoses for these patient visits relate to mental health/addictions, gastrointestinal complaints and infection. Conclusion: This study has shown that a significant number of our super-user population are receiving multiple CTs. Our next step is collect data on individual radiation doses and calculate exposure risks. We hope to inform policy and decision-makers who are developing programs to treat the underlying cause of their high resource use.
P050: The Northern Amazing and Awesome Model: Using positive deviance to impact patient care
Authors: Ohle R. , McIsaac S. 
Published: May 2020

Introduction: Positive deviance recognizes that there are individuals and teams within our community of practice that succeed in spite of system constraints. Amazing and awesome rounds has been proposed as a forum to identify behaviours and processes that lead to exceptional results. The objective of this study was to determine the feasibility and acceptability of a structured amazing and awesome rounds model through an innovative educational intervention. Methods: The authors engaged a broad range of professional designations(physicians, surgeons, nurses, respiratory therapists, administrative staff) at a tertiary care institution. A&A rounds were open to all allied health professionals and administrative staff. The Northern A&A rounds model was developed, implemented, and then evaluated as a four-part intervention. This consisted of: 1) Allied health professional training on case selection and analysis, 2) Engaging inter professional members, 3) disseminating lessons learned, and 4) creating an administrative pathway for acting on issues identified through the A&A rounds. The measures of intervention feasibility included the proportion of sessions adherent to the new model and A&A rounds attendance. Post intervention surveys of presenters and attendees were used to determine intervention acceptability. A&A presentation content was reviewed to determine the most frequently adopted components of the model. Results: Nine out of 9(100%) of presented cases were adherent to the three components of the Northern A&A Model. A&A rounds were highest attended of all hospital wide grand rounds(N = 75 SD 2.4 P < 0.001). Nine case presentations were analyzed and 7 action items were identified for amplification across the hospital. Including 3 case reports published of a novel approach to a patient case,a rapid referral for trauma patients at risk for PTSD, AED placement in all community clinics and routine debrief after resuscitations. Presenters included a broad representation of hospital staff including surgeons, emergency physicians, radiologists, nurses, and administrators. Conclusion: The Northern A&A Model was a feasible intervention that was perceived to be effective by both presenters and attendees. The authors believe that this could be readily applied to any hospital seeking to enhance quality of care and patient safety.