bluuebunny/crossref_metadata_2025_split huggingface dataset:
LO58: Using volunteers to improve the experience of older patients in the emergency department
Authors: Ellis B. , Melady D. , Foster N. , Sinha S. , Lau V. , Saraga S. , McLeod S. 
Published: May 2020

Introduction: The Maximizing Aging Using Volunteer Engagement in the ED (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program and the activities performed with older patients by its volunteers. Methods: The MAUVE + ED program was implemented in the ED (annual census 65,000) of a large academic tertiary hospital in Toronto, Ontario. Volunteers were trained to identify and approach older patients and others at greater risk for adverse outcomes, including poor patient experience, in the ED and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. Results: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median (IQR) time a MAUVE volunteer spent with a patient was 10 (5, 20) minutes, with a range of 1 to 130 minutes. The median (IQR) number of patients seen per shift was 7 (6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). Conclusion: Preliminary data suggest the MAUVE + ED volunteers were able to enrich the experience of older adults and their families/carers in the ED.
LO76: Effect of task interruptions training on the quality of simulated ALS
Authors: Truchot J. , Michelet D. , Drummond D. , Freund Y. , Plaisance P. 
Published: May 2020

Introduction: Task interruptions are reportedly frequent disturbances for emergency physicians performing advanced life support (ALS). The aim of this study was to evaluate the benefit of adding task interruptions in ALS simulated training session. Methods: We conducted a multi centered randomized controlled trial in four emergency departments of a university hospital in Paris, France. Each emergency team included one resident, one nurse and one emergency physician. The teams were randomized for the nature of their training session: control (without interruption) or realistic (with interruptions). The interruption consisted of an interfering family member speaking a foreign language, and of repetitive phone calls during ALS. After the first training session, teams were evaluated on a second realistic session with task interruptions. The primary outcome was non-technical skills assessed with the TEAM score during this evaluation session. We also measured the no flow time, and the Cardiff score, which reflects the quality of ALS: including chest compression depth and rate, no flow time. Results: On a total of 23 included teams, 12 had a control training session and 11 with task interruptions. Baseline characteristics and TEAM score were similar between the two groups (Mean difference: 3,3 [-2,2; 8,9]; p = 0,26). During the evaluation session, the TEAM score was lower for “realistic” teams (mean difference -8 [95% confidence interval -13; -3]). We also report a higher no flow time and similar overall Cardiff score. Conclusion: In this simulated ALS study, the presence of disturbances during simulation seemed to worsen the quality of training. This study highlights the negative consequences of task interruptions in emergency medicine.
LO78: Ready for launch? A survey of readiness factors among 2019 Competence By Design launch disciplines
Authors: Cheung W. , Hall A. , Dalseg T. , Oswald A. , Cook L. , Melle E. Van , Frank J. 
Published: May 2020

Introduction: A critical component for successful implementation of any innovation is an organization's readiness for change. Competence by Design (CBD) is the Royal College's major change initiative to reform the training of medical specialists in Canada. The purpose of this study was to measure readiness to implement CBD among the 2019 launch disciplines. Methods: An online survey was distributed to program directors of the 2019 CBD launch disciplines one month prior to implementation. Questions were developed based on the R = MC2 framework for organizational readiness. They addressed program motivation to implement CBD, general capacity for change, and innovation-specific capacity. Questions related to motivation and general capacity were scored using a 5-point scale of agreement. Innovation-specific capacity was measured by asking participants whether they had completed 33 key pre-implementation tasks (yes/no) in preparation for CBD. Bivariate correlations were conducted to examine the relationship between motivation, general capacity and innovation specific capacity. Results: Survey response rate was 42% (n = 79). A positive correlation was found between all three domains of readiness (motivation and general capacity, r = 0.73, p < 0.01; motivation and innovation specific capacity, r = 0.52, p < 0.01; general capacity and innovation specific capacity, r = 0.47, p < 0.01). Most respondents agreed that successful launch of CBD was a priority (74%). Fewer felt that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). While most programs indicated that their leadership (94%) and faculty and residents (87%) were supportive of change, 42% did not have experience implementing large-scale innovation and 43% indicated concerns about adequate support staff. Programs had completed an average of 72% of pre-implementation tasks. No difference was found between disciplines (p = 0.11). Activities related to curriculum mapping, competence committees and programmatic assessment had been completed by >90% of programs, while <50% of programs had engaged off-service rotations. Conclusion: Measuring readiness for change aids in the identification of factors that promote or inhibit successful implementation. These results highlight several areas where programs struggle in preparation for CBD launch. Emergency medicine training programs can use this data to target additional implementation support and ongoing faculty development initiatives.
LO93: A single center randomized control trial of intravenous lidocaine for the management of traumatic rib fractures
Authors: Patton P. , Vogt K. , Parry N. , Priestap F. , Ball I. 
Published: May 2020

Introduction: Traumatic rib fractures (RF) are a common occurrence with 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and reducing morbidity and mortality. There is evidence of intravenous (IV) lidocaine's effectiveness and safety in the post-operative thoracic and abdominal surgical patient and we hypothesize that it may be ideal in trauma patients with RF. We evaluated IV lidocaine's analgesic efficacy in this population. Methods: A single-centre, double-blind, randomized control trial comparing a 72-96 hour IV lidocaine infusion plus standard analgesics to placebo infusion plus standard analgesics. Participants were adult trauma patients diagnosed with two or more RFs requiring hospital admission. A total of 36 patients were enrolled over 5 months in 2019. The study was powered to detect a 20% reduction in pain scores, which is determined to be clinically significant. Results: The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). There were consistent trends toward reduced VAS pain scores at rest and with movement in the lidocaine group as compared to placebo group with mean scores of 3.49 [SD 2.02 95% CI] and 7.08 [SD 1.71 95% CI] in the lidocaine group and 3.83 [SD 1.93 95% CI] and 8.03 [SD 1.44 95% CI] in the placebo group, at rest (p value 0.624) and with movement (p value 0.110), respectively . Secondary outcomes were patient satisfaction as measured on the VAS which demonstrated a score of 7.79 [SD 1.82 95% CI] in the lidocaine group and 6.63 [SD 1.77 95% CI] (p = 112) in the placebo group, and total morphine equivalents (ME) used (including breakthrough doses) that demonstrated a trend towards a reduction in the lidocaine group with 210.9 mg [SD 180.0 95% CI] compared to the placebo with total ME used of 309.9 mg [SD 221.8 95% CI]. Other secondary outcomes were protocol adherence, incidence of respiratory failure, hospital and ICU length of stay, mortality, incidence of lidocaine toxicity, and treatment regimens (non-opioid analgesics). Conclusion: These results demonstrate a trend towards lidocaine's analgesic benefit during rest and the critical times of patient movement and mobility, which has been demonstrated to be paramount in the reduction of respiratory complications from rib fractures. The results also tend towards a reduction in morphine equivalents, although the trial was not powered to demonstrate this
MP02: The impact of adoption of an electronic health record on emergency physician work: a time motion study
Authors: Calder-Sprackman S. , Clapham G. , Kandiah T. , Choo-Foo J. , Aggarwal S. , Sweet J. , Abdulkarim K. , Price C. , Thiruganasambandamoorthy V. , Kwok E. 
Published: May 2020

Introduction: Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED). Methods: We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison. Results: All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99). Conclusion: Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.
MP08: Using administrative data to explore emergency department management of patients presenting with acute atrial fibrillation/flutter: Is Shock-First a more effective strategy than Drug-Shock?
Authors: Rowe B. , Bohlouli B. , Villa-Roel C. 
Published: May 2020

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias managed in the emergency department (ED). Equipoise in cardioversion strategies for patients with recent onset AFF contributes to observed practice variation. Using administrative data, the objective of this study was to explore the pattern of practice and the comparative effectiveness (outcomes and costs) between Shock-First and Drug-Shock approaches in AFF. Methods: Adult patients >17 years of age with AFF from one academic Canadian hospital ED were eligible. Using administrative data linkage among the National Ambulatory Care Record System, provincial practitioner claims data repository and a local hospital pharmacy database, patients who received treatment with procainamide and/or electrical cardioversion for AFF were identified. Outcomes including disposition, length of stay, revisit within 72 hours and 30-days, and ED costs were analyzed over a seven-year period. Categorical variables are reported as percentages. Continuous variables are reported as median and interquartile range (IQR). Univariate and multivariate logistic regression analyses were completed and reported as odds ratios (OR) and 95% confidence intervals (CI). Results: Overall, 5,372 patients were identified with AFF; the median age was 70 years and 55% were male. The majority of patients had chronic or secondary AFF; however, in 1687 (31%) cardioversion options were employed for presumed were recent onset AFF. A Shock-First strategy was most common (1379 {82%}); 308 (18%) received a Drug-Shock approach. Discharge time was 33 minutes (95% CI: 4–63) longer in the Drug-Shock approach compared to the Shock-First approach. Hospital admissions were higher (OR = 2.33; 95% CI: 1.68, 3.24) and revisits within 30-days were lower (OR = 0.74; 95% CI: 0.54, 0.95) in the Drug-Shock group. The Shock-First strategy demonstrated marginally higher costs (median = $106 CND; 95% CI: $68.89, $144.40) in adjusted analyses. Conclusion: In patients with acute AFF, when cardioversion was attempted, a Shock-First strategy was employed 80% of the time and resulted in shorter ED length of stay and lower hospitalization; however, higher costs and ED revisits within 30-days were observed. Many factors, including physician and/or patient preferences, influence ED decision-making in patients with AFF and understanding the factors influencing these decisions requires further attention.
MP15: Predictors of emergency department opioid use and variability of prescribing practices in a large multicenter Canadian cohort
Authors: Lau T. , Hayward J. , Innes G. 
Published: May 2020

Introduction: Emergency department (ED) opioid prescribing has been linked to long-term use and dependence. Anecdotally, significant opioid practice variability exists between physicians and institutions, but this is poorly defined. Our objective was to collate and analyze multicenter data looking at predictors of ED opioid use and to identify potential areas for opioid stewardship. Methods: We linked administrative and computerized physician order entry (CPOE) data from all four ED's within our municipality over a one-year period. Eligible patients included those with a Canadian Triage and Acuity Scale (CTAS) pain complaint or an arrival numeric rating scale (NRS) pain score of greater than 3/10. Patients with missing demographic or chief complaint data were excluded. Multiple imputation was used for missing NRS pain scores. We performed descriptive analyses of opioid-treated and non-treated patients, followed by a multivariable logistic regression to identify predictors of ED opioid administration. Results: A total of 129,547 patients were studied. The mean age was 47.4 years and 55.4% were female. The median pain score was 6.6 in the no-opioid group and 8 in the opioid group. The most common pain categories were abdominal pain (23%), trauma (18.2%) and chest pain (15.3%). Overall, opioids were prescribed to 34% of patients. The most common CTAS score was CTAS 3 (44%), CTAS 1-2 42%) and CTAS 4-5 (13.9%). Multivariable predictors of opioid-use included the need for admission (adjusted OR 6.57; CI = 6.34-6.79), NRS pain score (aOR 1.24 per unit increase, CI 1.23-1.25), higher numerical CTAS score (aOR 0.89 per unit increase, CI 0.87-0.91), and chief complaints of back (aOR 7.69, CI 7.1-8.1), abdominal (aOR 5.9, CI 5.6-6.2), and flank pain (OR 3.8, CI 3.5-4). Oral opioids were prescribed in 39.8% of back pain presentations and 18.5% received IV opioids. Increasing age was a predictor but sex was not. There were significant institutional differences in opioid prescribing rates, with Hospital B being the least likely to prescribe opioids (aOR 0.82, CI 0.80-0.85) followed by Hospital C (aOR 0.83, CI 0.79-0.86) compared to the reference standard of Hospital A. Hospital D was most likely to prescribe opioids (aOR 1.32, CI 1.27-1.37). Conclusion: Predictors of ED opioid use were characterized using multicenter administrative data. Future research should seek to describe the physician- and site-level factors driving regional variation in opioid-based pain treatment.
MP31: Optimizing ketorolac dosing by leveraging computerized order entry
Authors: Pompa N. , Bond C. , Wang D. , Dowling S. 
Published: May 2020

Background: Ketorolac has long been used to manage pain in the Emergency Department and has the advantage of being the only parenteral NSAID formulation. Despite multiple studies demonstrating an analgesic ceiling dose of 10mg for intravenous ketorolac, higher doses (30-60mg) are commonly ordered. Use of optimal doses of ketorolac (10mg) has the advantage of lower side effects and cost. Aim Statement: The aim of this project was to increase the usage of the optimal dose parenteral ketorolac (10mg) without increasing the use of additional, concomitant or rescue opioids (balancing measures). Measures & Design: This pre-/post-intervention comparison study (May 1, 2016 to April 30, 2018) included all patients ≥18 years of age that received parenteral ketorolac at one of 4 EDs in the Calgary zone. All data was captured via administrative data records. Stakeholders (ED leadership, analgesia committee, nursing and pharmacy) provided feedback and support for the project. Our multi-modal intervention included modifying all ED computerized order sets such that the default parenteral ketorolac dose was 10mg (post-intervention) from 30mg (pre-intervention), education (dissemination of evidence to support the changes to clinicians) and our pharmacy securing 10mg vials of ketorolac. At their discretion, physicians’ were still able to order other doses of ketorolac. Evaluation/Results: During the 2 year study period, 19290 patient records were identified where parenteral ketorolac was administered during the ED visit. Baseline characteristics were similar between the pre/post periods. Prior to the change in default dosing, 10.5% of orders were for ketorolac 10mg compared to 87% in the post-intervention period (p < 0.000). Statistical process charts support the above results and demonstrate that the changes have been sustained. There were no differences in patients receiving ketorolac as the only analgesic between the pre/post periods (42% vs 42%, p = 0.396), nor where there significant changes in concomitant opioid usage (46% vs 46%, p = 0.817), or rescue analgesia (11% vs 12%, p = 0.097). Discussion/Impact: In this large cohort, our multi-modal intervention, resulted in a significant increase in optimal ketorolac parenteral dosing without a significant change in additional opioid use. The results support the utility of computerized order set changes as the cornerstone of an effective and rapid knowledge translation strategy to align physician practice with best evidence.
MP34: Block that Hip! Improving rates of ultrasound-guided fascia iliaca compartment blocks for hip fracture analgesia in the emergency department: a quality improvement initiative
Authors: Crickmer M. , Cameron A. , Smith D. , Ward S. , Wong A. , Wong K. , Cheng A. , Chu J. , Lockwood J. , Petrosoniak A. , Vaillancourt S. 
Published: May 2020

Background: In patients with acute hip fracture, a fascia iliaca compartment block (FICB) has been shown to provide effective non-opioid analgesia, reduce the incidence of pneumonia, and potentially decrease the rate of delirium [1]. However, this procedure was infrequently used in the St. Michael's Hospital (SMH) emergency department (ED). Aim Statement: Our aim was to increase the proportion of patients with hip fracture receiving FICB in the ED to 50% in six months. Measures & Design: We completed two Plan-Do-Study-Act (PDSA) cycles, measuring rates of FICB before and after each cycle. The first was a departmental rounds presentation with information about the process and benefits of FICB, addressing barriers identified by surveying the group. The second cycle included a bundle of interventions comprising of an “instruction card” with the steps required to do the procedure, access to a video tutorial, and a list of experienced physicians willing to help less experienced providers perform FICB. Evaluation/Results: In the three months prior to the project, the rate of FICB in the ED was 12.5% (3/24). For the three months after the first PDSA cycle, the rate increased to 22.2% (8/36). Then, the second cycle was performed. In the following two months the rate further increased to 36.8% (7/19). Discussion/Impact: Despite the clear increase in FICB rate, these changes were not statistically significant (p = 0.063). Our methodology was shown to be safe and effective, and our model can be applied to other ED groups looking to increase their rates of FICB.