bluuebunny/crossref_metadata_2025_split huggingface dataset:
LO56: Rate of delirium recognition by nurses and physicians in a cohort of 1584 older emergency department patients: how many would have been sent home?
Authors: Lee J. 
Published: May 2020

Introduction: Unrecognized delirium in the ED remains common despite a 3 fold mortality increase for those discharged home. But previous studies have not assessed delirium recognition rate in a multicenter study nor assessed the management plans of ED staff when they fail to recognize delirium. Objectives: To document 1) the rate of delirium recognition by nurses and MDs in a national sample and 2) the intended management plans for patients with unrecognized delirium. Methods: This is a planned sub-study of a randomized clinical trial at 5 EDs in 4 provinces conducted in English and French. We included people ≥ 65 years old. We excluded those with an ED stay < 4 hours, critical illness, visual impairment or from a nursing home. Research assistants (RAs) assessed delirium using the validated Confusion Assessment Method. RAs then asked ED nurses and physicians if the patient had delirium according to their clinical assessment. RAs also asked how confident they were that the patient could be safely discharged home using a 10 point Likert scale. We report proportions and 95% confidence intervals. RAs notified all ED staff of unrecognized CAM + ve patients prior to actual discharge for safety reasons. Results: We recruited 1584 older people; 1496 (92.5%) had complete data. Mean age was 76.5; 49% were female. Nurses performed 1465 delirium assessments. There were 76 CAM + ve patients in our sample (5.2%, 95% CI 4.2 to 6.5%). Nurses recognized delirium in 34/76 (44.7%, 95% CI: 33.3 to 56.6%). MDs assessed 20 CAM + ve patients and recognized the delirium in 10/20 (50.0%, 95% CI: 27.2 to 72.8). Nurses felt that 11/42 patients with unrecognized delirium could be discharged (26.2% 95% CI: 13.9 to 42.0%). Their median confidence in the safety of their plan was 7.0/10. MDs felt that 2/10 patients with unrecognized delirium could be discharged (20.0% 95% CI: 2.5 to 55.0%). Their median confidence in the safety of their plan was 7.5/10. Conclusion: Despite the potential Hawthorne effect raising initial delirium recognition rates above clinicians’ usual practice outside of a study, delirium recognition by both nurses and MDs remains poor in a national sample of ED patients. We also showed that a significant number of these patients could have been discharged with unrecognized delirium. Further research to find novel ways to improve delirium recognition is needed.
LO59: Reliability of patient reported exposure and outcome data in a prospective cohort study of older adults presenting to the emergency department
Authors: Selvanayagam N. , Soomro A. , Varner C. , McLeod S. , Clayton N. , de Wit K. 
Published: May 2020

Introduction: Participant interviews are often considered the ‘gold standard’ for measuring outcomes in diagnostic and prognostic studies. Participant exposure data are frequently collected during study interviews, but the reliability of this information often remains unknown. The objective of this study was to compare patient-reported medication exposures and outcomes to data extracted from electronic medical records (EMRs) to determine reliability. Methods: This was a secondary data analysis from a prospective observational cohort study enrolling older (≥ 65 years) patients who presented to one of three emergency departments after a fall. After patients had consented to participate in the study, they were asked about their use of antiplatelet and anticoagulation medications (exposures of interest). During follow up, participants were asked if a physician had told them they had bleeding in their head (diagnosis of intracranial hemorrhage). Patient-reported responses were compared to data extracted from a structured EMR review. Trained research assistants extracted medication exposure and outcome data from the hospital EMRs in duplicate for all visits to any hospital within 42 days. Inter-rater agreement was estimated using Cohen's kappa (K) statistics with 95% confidence intervals (CIs). Results: 1275 patients completed study interviews. 1163 (91%) responded to questioning about antiplatelet use and 1159 (91%) to anticoagulant use. Exact agreement between patient reported antiplatelet use compared to EMR review was 77%, with K = 0.50 (95% CI: 0.44 to 0.55). For anticoagulation use, exact agreement was 87%, with K = 0.68 (95% CI: 0.63 to 0.72). 986 (78%) patients had a follow up interview after 42 days. Exact agreement between patient reported intracranial bleeding and EMR review was 95%, with K = 0.30 (95% CI: 0.15 to 0.45). Using the EMR review as the reference standard, the sensitivity and specificity of patient reported intracranial bleeding was 34% (95% CI: 20 to 52%) and 97% (95% CI: 96 to 98%), respectively. Conclusion: In this population of older adults who presented to the ED after a fall, patient reported use of antiplatelet and anticoagulant medications was not a reliable method to identify medication use. Patients who were diagnosed with intracranial bleeding were particularly poor at reporting this diagnosis.
LO61: A modified Delphi study to identify trauma care modifiers for older adults
Authors: Yadav K. , Boucher V. , Le Sage N. , Malo C. , Mercier E. , Voyer P. , Clement J. , Emond M. 
Published: May 2020

Introduction: Older (age >=65 years) trauma patients suffer increased morbidity and mortality. This is due to under-triage of older trauma victims, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. There are currently no Canadian guidelines for the management of older trauma patients. The objective of this study was to identify modifiers to the prehospital and emergency department (ED) phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study to assess senior-friendly major trauma care modifiers based on national expert consensus. The panel consisted of 24 trauma care providers across Canada, including medical directors, paramedics, emergency physicians, emergency nurses, trauma surgeons and trauma administrators. Following a literature review, we developed an online Delphi survey consisting of 16 trauma care modifiers. Three online survey rounds were distributed and panelists were asked to score items on a 9-point Likert scale. The following predetermined thresholds were used: appropriate (median score 7–9, without disagreement); inappropriate (median score 1–3; without disagreement), and uncertain (any median score with disagreement). The disagreement index (DI) is a method for measuring consensus within groups. Agreement was defined a priori as a DI score <1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panelists. Of 19 trauma care modifiers, the expert panel achieved consensus agreement for 17 items. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate <10 or >20 breaths/minute or needing ventilatory support (DI = 0.24). The ED modifier with the strongest level of agreement was obtaining a 12-lead electrocardiogram following the primary and secondary survey for all older adults (DI = 0.01). Two trauma care modifiers failed to reach consensus agreement: transporting older patients with ground level falls to a trauma centre and activating the trauma team based solely on an age >=65 years. Conclusion: Using a modified Delphi process, an expert panel agreed upon 17 trauma care modifiers for older adults in the prehospital and ED phases of care. These modifiers may improve the delivery of senior-friendly trauma care and should be considered when developing local and national trauma guidelines.
LO64: A systematic review of interventions to influence opioid prescribing from the emergency department
Authors: Tran M. , Thompson C. , Walsh C. , McLeod S. , Borgundvaag B. 
Published: May 2020

Introduction: The opioid crisis has reached epidemic levels in Canada, driven in large part by prescription drug use. Emergency physicians are frequent prescribers of opioids; therefore, the emergency department (ED) represents an important setting for potential intervention to encourage rational and safe prescribing. The objective of this study was to systematically review the literature on interventions aimed to influence opioid prescribing in the ED. Methods: Electronic searches of Medline and Cochrane were conducted and reference lists were hand-searched. All quantitative studies published in English from 2009 to 2019 were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible studies, the full texts of which were retrieved and assessed for inclusion. Outcomes of interest included opioid prescribing rate (proportion of ED visits resulting in an opioid prescription at discharge), morphine milligram equivalents per prescription and variability among prescribers. Results: The search strategy yielded 797 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 34 potentially relevant studies were retrieved in full text. Of these, 28 studies were included in the review. The majority (26, 92.9%) of studies were based in the United States and two (7.1%) were from Australia. Four (14.3%) were randomized controlled trials. The interventions were classified into six categories: prescribing guidelines (n = 10), regulation/rescheduling of opioids (n = 6), prescribing data transparency (n = 4), education (n = 4), care coordination (n = 3), and electronic medical record changes (n = 1). The majority of interventions reduced the opioid prescribing rate from the ED (21/28, 75.0%), although regulation/rescheduling of opioids had mixed effectiveness, with 3/6 (50%) studies reporting a small increase in the opioid prescribing rate post-intervention. Education had small yet consistent effects on reducing the opioid prescribing rate. Conclusion: A variety of interventions have attempted to improve opioid prescribing from the ED. These interventions include prescribing guidelines, regulation/rescheduling, data transparency, education, care coordination, and electronic medical record changes. The majority of interventions reduced the opioid prescribing rate; however, regulation/rescheduling of opioids demonstrated mixed effectiveness.
LO73: Are women under-represented in emergency medicine residency programs across Canada?
Authors: Lien K. , Yau L. , Aarsen K. Van , Wakabayashi A. , Bhimani M. 
Published: May 2020

Introduction: 2018 data from the Canadian Medical Association website shows that of practicing emergency physicians country-wide, only 31% were female. While there are some studies that examine the number and proportion of Canadian female applicants applying to surgical specialties, there are very few studies that are specific to emergency medicine (EM), and none that are Canadian in scope. Given the changing gender ratio of graduating medical students in Canada, the primary objective of this study is to assess the mean proportion and trends in proportion of females who applied and matched to English-language Canadian EM programs including Canadian College of Family Physicians emergency medicine certificate (CCFP-EM) and Fellow of the Royal College of Physicians of Canada emergency medicine (FRCPC-EM), family medicine (CCFP) programs, and all specialties combined. Methods: A retrospective data analysis on residency match results from 2013-2019 inclusively was performed. Data was accessed through a freedom of information request from the Canadian resident matching service (CaRMS). The mean proportions and trends in the proportions of females applying and matching to CCFP-EM, FRCPC-EM, CCFP, and all specialties were computed. Cochrane-Armitage trend of test was used for analysis. Results: From 2013-2019, the mean (SD) percentage of females who applied and matched respectively were as follows: CCFP-EM [44.4 (3.5);46.0(4.5)]; FRCPC-EM [41.3(4.1);44.0 (4.5], CCFP [56.5(1.3);61.0(1.9)], all specialties [54.0(1.1);55.5(0.9)]. There was a significant increase in the proportion of female applying to the FRCPC-EM (p < 0.0001), CCFP (p = 0.0002), and all disciplines (p = 0.0013). There was no significant change in the proportion of females applying for the CCFP-EM program (p = 0.6435). Conclusion: Our study shows that there is an increasing trend in the percentage of female applicants in all programs except the CCFP-EM program, where it remained statistically the same over time. There was a consistent percentage of applied versus matched female applicants over time for both CCFP-EM and FRCPC-EM programs. However, the percentage of females applying or matching to both CCFP-EM and FRCPC-EM programs remained less than 50%. Further research could focus on evaluating reasons for program choice, in order to further increase the percentage of female medical students and residents applying and matching to both emergency medicine programs.
LO81: The use of in situ simulation to improve emergency department staff comfort with the management of high acuity, low occurrence cases
Authors: Bilic M. , Hassall K. , Hastings M. , Fraser C. , Rutledge G. , Hanel E. 
Published: May 2020

Introduction: In the emergency department (ED), high-acuity presentations encountered at low frequencies are associated with reduced staff comfort. Previous studies have shown that simulation can improve provider confidence with practical skills and management of presentations in various fields of medicine. The present study examined the effect of in situ simulation on interprofessional provider comfort with the identification and management of high-acuity low-frequency events in the ED. It further assessed the feasibility of implementing weekly simulation as an interprofessional education initiative in a high-volume ED. Methods: This was a retrospective pre-test post-test quasi-experimental design. Weekly in situ simulation events were facilitated by an interdisciplinary team in a high-volume ED in Hamilton, Ontario that sees an average of 185 patients per day. To date, 34 simulation events were held between January 18, 2019 and November 22, 2019, and included neonatal, paediatric and obstetric emergencies, and adult codes. There was an average of 20 patients presenting to the ED during these events. Events included a debrief, and typically lasted 60 minutes in total. Participants included individuals from various disciplines working on shift at the time of the event. Questionnaires were administered via email following the event, in which participants were asked to rank their comfort with emergency codes before and after the simulation using two 5-point Likert scales. The data from 39 questionnaires was analyzed. T-tests were used to analyze differences in self-reported comfort scores. Results: Questionnaire responders included nurses (41%), respiratory therapists (26%), resident physicians (10%), paramedics (3%), attending physicians (3%), students of various disciplines (10%) and other (7%). 38% of participants reported increases in comfort following simulation when compared to prior. Using the 5-point scale, the average reported score for comfort pre-simulation was 3.59 (95% CI 3.30–3.88), and the average post-simulation score was 3.97 (95% CI 3.76–4.19, p = 0.03). Conclusion: Our results demonstrate that weekly interprofessional in situ simulation is feasible in a high-volume ED, and significantly improves self-reported provider comfort with the identification and management of high-acuity, low-frequency events. This warrants the implementation of this simulation design to improve staff confidence and has implications for its potential role in improving team dynamics and patient safety.
LO82: Exploring eye-tracking technology to assess competency in point-of-care ultrasound
Authors: Lee W. , Chenkin J. 
Published: May 2020

Introduction: Assessment of point-of-care ultrasound (POCUS) competency has been reliant on practical, visual and written examinations performed 1-on-1 with an examiner. These tools attempt to assess competency through subjective ratings, checklists and multiple-choice questions that are labour intensive using surrogate measures. Eye-tracking has been used on a limited basis in various fields of medicine for training and assessment. This technology explores visual processing and holds great promise as a tool to monitor training progress towards the development of expertise. We hypothesize that eye-tracking may differentiate novices and experts as they progress to become competent in interpretation of POCUS images and provide an objective measure in assessment of competency. Methods: Medical students, residents and attending physicians working in an academic emergency department were recruited. Participants viewed a series of 16 ultrasound video clips in a POCUS protocol for Focused Assessment using Sonography in Trauma (FAST). The gaze pattern of the participants was recorded using a commercially available eye-tracking device. The primary outcome was the gaze parameters including total gaze time in the area of interest (AOI), average time to fixation on the AOI, number of fixations in the AOI and average duration of first fixation on the AOI. Secondary outcome was the accuracy on the interpretation of the FAST scan. Results: Four novices and eight experts completed this study. The total gaze time in the AOI (mean +/- SD) was 76.72 +/- 18.84s among experts vs 53.64 +/- 10.33s among novices (p = 0.048), average time to fixation on the AOI was 0.561 +/- 0.319s vs 1.048 +/- 0.280s (p = 0.027), number of fixations in the AOI was 158.9 +/- 29.0 vs 121.8 +/- 17.5 (p = 0.042) and average duration of first fixation was 0.444 +/- 0.119s vs 0.390 +/- 0.024s (p = 0.402). The accuracy of the answers was 79.7 +/- 14.1% vs 45.3 +/- 21.9% (p = 0.007). Conclusion: In this pilot study, eye tracking shows potential to differentiate between POCUS experts and novices by their gaze patterns. Gaze patterns captured by eye tracking may not necessarily translate to cognitive processing. However, it allows educators to visualise the thought processes of the learner by their gaze patterns and provide insight on how to guide them towards competency. Future studies are needed to further validate the metrics for competency in POCUS applications.
LO83: Effect of the transition to an entrustability scale on assessor stringency and leniency on daily encounter cards in emergency medicine
Authors: Dewhirst S. , Cheung W. , Dudek N. , Wood T. , Frank J. 
Published: May 2020

Introduction: Workplace based assessments (WBAs) are integral to emergency medicine residency training. However many biases undermine their validity, such as an assessor's personal inclination to rate learners leniently or stringently. Outlier assessors produce assessment data that may not reflect the learner's performance. Our emergency department introduced a new Daily Encounter Card (DEC) using entrustability scales in June 2018. Entrustability scales reflect the degree of supervision required for a given task, and are shown to improve assessment reliability and discrimination. It is unclear what effect they will have on assessor stringency/leniency – we hypothesize that they will reduce the number of outlier assessors. We propose a novel, simple method to identify outlying assessors in the setting of WBAs. We also examine the effect of transitioning from a norm-based assessment to an entrustability scale on the population of outlier assessors. Methods: This was a prospective pre-/post-implementation study, including all DECs completed between July 2017 and June 2019 at The Ottawa Hospital Emergency Department. For each phase, we identified outlier assessors as follows: 1. An assessor is a potential outlier if the mean of the scores they awarded was more than two standard deviations away from the mean score of all completed assessments. 2. For each assessor identified in step 1, their learners’ assessment scores were compared to the overall mean of all learners. This ensures that the assessor was not simply awarding outlying scores due to working with outlier learners. Results: 3927 and 3860 assessments were completed by 99 and 116 assessors in the pre- and post-implementation phases respectively. We identified 9 vs 5 outlier assessors (p = 0.16) in the pre- and post-implementation phases. Of these, 6 vs 0 (p = 0.01) were stringent, while 3 vs 5 (p = 0.67) were lenient. One assessor was identified as an outlier (lenient) in both phases. Conclusion: Our proposed method successfully identified outlier assessors, and could be used to identify assessors who might benefit from targeted coaching and feedback on their assessments. The transition to an entrustability scale resulted in a non-significant trend towards fewer outlier assessors. Further work is needed to identify ways to mitigate the effects of rater cognitive biases.
LO84: The incidence of fall-related intracranial bleeding in older adults taking anticoagulants, antiplatelets and neither medication: a meta-analysis
Authors: de Wit K. , Nishijima D. , Mason S. , Jeanmonod R. , Parpia S. , Varner C. , Mercuri M. , Kuczawski M. , Germini F. , Kagoma Y. , Mercier É. 
Published: May 2020

Introduction: It is unclear whether anticoagulant or antiplatelet medications increase the risk for intracranial bleeding in older adults after a fall. Our aim was to report the incidence of intracranial bleeding among older adults presenting to the emergency department (ED) with a fall, among patients taking anticoagulants, antiplatelet medications, both medications and neither medication. Methods: This was a systematic review and meta-analysis, PROSPERO reference CRD42019122626. Medline, EMBASE (via OVID 1946 - July 2019), Cochrane, Database of Abstracts of Reviews of Effects databases and the grey literature were searched for studies reporting on older adults who were evaluated after a fall. We included prospective studies conducted in the ED where more than 80% of the cohort were 65 years or older and had fallen. We contacted study authors for aggregate data on intracranial bleeding in patients prescribed anticoagulant medication, antiplatelet medication and neither medication. Incidences of intracranial bleeding were pooled using random effect models, and I2 index was used to assess heterogeneity. Results: From 7,240 publication titles, 10 studies met inclusion criteria. The authors of 8 of these 10 studies provided data (on 9,489 patients). All studies scored low or moderate risk of bias. The pooled incidence of intracranial bleeding among patients taking an anticoagulant medication was 5.1% (n = 5,016, 95% Confidence Interval (CI): 4.1 to 6.3%) I2 = 42%, a single antiplatelet 6.4% (n = 2,148, 95% CI: 5.4 to 7.6%) I2 = 75%, both anticoagulant and antiplatelet medications 5.9% (n = 212, 95% CI: 1.3 to 13.5%) I2 = 72%, and neither of these medications 4.8% (n = 1,927, 95% CI: 3.5 to 6.2%) I2 = 50%. A sensitivity analysis restricted to patients who had a head CT in the ED reported incidences of 6.1% (n = 3,561, 95% CI: 3 to 8.3%), 8.4% (n = 1,781, 95% CI: 5.5 to 11.8%), 6.7% (n = 206, 95% CI 1.5 to 15.2%) and 6.6% (n = 1,310, 95% CI: 5.0 to 8.4%) respectively. Conclusion: The incidence of fall-related intracranial bleeding in older ED patients was similar among patients who take anticoagulant medication, antiplatelet medication, both and neither medication, although there was heterogeneity between study findings.