Introduction: Safe and efficient provision of quality healthcare requires maintenance of knowledge and skills relevant to daily practice. This is particularly relevant in rural and remote locations where high-acuity low-occurrence procedures and clinical scenarios present even less frequently. Simulation based training is widely used to supplement clinical exposure and practice but effective delivery of this approach to the rural/ remote practitioner must address barriers of time, cost and geographical separation. Mobile tele-simulation is an innovative approach that may help in bridging the gap through delivery of effective mentoring using telemedicine technologies and tailored educational content. Methods: To help direct the iterative design cycle for the mobile tele-simulation unit, input from potential future users was felt to be essential. The Delphi method was employed to reach consensus among study participants on four key questions: 1) What applications would the MTU be best suited for?, 2) What technical requirements and teaching tools would be needed to make the MTU successful?, 3) Which fields, besides EM/medical education, may benefit from partnerships with the final MTU?, 4) What research studies could be developed using the MTU? It was decided in advance that two rounds would be the maximum due to time constraints of the larger MTU projects. The first questionnaire focused on demographics and the four questions above. Independent reviewers analyzed, compiled and compared responses. Participants were sent the updated list, asked to confirm their responses and then to rank the responses highest to lowest priority. Results: Fifteen of 17 first round participants completed the questions, giving an 88.2% response rate. All shared a simulation background. 66% were physicians, 13.3% medical students, and 20% staff at Memorials Simulation Center. 66% had been involved with simulation-based education less than 5 years, and the others greater than 5 year. 13 of 15 (86.7%) responded in round 2. Consensus was not reached statistically using Kendalls W test for each of the four questions. However, there were several responses that showed higher median ranks than the others under each question. Application use: rural healthcare training, and medical professional training Technical factors: reliable learner-mentor connection, and competent technical support Non-technical factors: knowledgeable mentor and content relevant to locations practice, Research studies: training needs assessment from rural sites, and learners experience compared to stationary simulation center Conclusion: Input from a heterogeneous group of simulation users was sought to help prioritize key features in the development of the Mobile Tele-simulation Unit. Although statistically the study did not reach consensus, valuable feedback was compiled and pragmatically applied in the iterative development cycle.

Introduction: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Canada. The Anthonisen criteria utilizes the cardinal symptoms of acute exacerbations of COPD (AECOPD), increased shortness of breath, increased sputum production, and increased sputum purulence, to determine which patients should receive antibiotics. In July 2015, a COPD Order Set Pilot was implemented in Saskatoon emergency departments (ED). The order set utilizes the Anthonisen criteria to optimize AECOPD patient management and ensure appropriate antibiotic usage. By January 2019, we aim to optimize AECOPD patient management in Saskatoon ED. We aim to increase physician uptake of the order set to 50% and to increase appropriate antibiotic prescription to 90%. Methods: Our project was designed following the Plan-Do-Study-Act method. Our primary outcome was to measure the rate of appropriate antibiotic prescription when managing AECOPD patients. Our secondary outcome was to measure physician uptake of the order set. We believed that a standardized order set would optimize patient care. We hypothesized that 80% of AECOPD patients would be managed with antibiotics appropriately and that 25% of emergency physicians would utilize the order set. A chart review was conducted examining AECOPD patient management in Saskatoon ED. The study period included the 6 months following the implementation of the order set. Our inclusion criteria were patients diagnosed with AECOPD and managed in the ED. Our exclusion criteria were patients currently prescribed antibiotics or patients requiring inpatient admission. A convenience sample of 125 charts was selected for review, enabling an accurate representation of order set utilization and antibiotic usage. A secondary reviewer abstracted a random 15% sample of the charts to ensure validity of the data. Results: Our results showed that, during our study period, none of the AECOPD patients were managed with the order set. Of the patients receiving antibiotic therapy, only 32 of the 53 (60.38%) met the Anthonisen criteria and were appropriately prescribed antibiotics. Of the patients not given antibiotics, 15 of the 42 (35.71%) met the Anthonisen criteria and should have been managed with antibiotics. These results refuted both of our hypotheses. Conclusion: As COPD is one of the leading causes of morbidity and mortality in Canada, proper management is crucial. Our results state that uptake of the order set is low and that antibiotic utilization is not optimized. These results demonstrate the need to modify and promote the current order set. We believe that by encouraging the use of the order set and streamlining the management guidelines, we can increase physician uptake. This will subsequently increase appropriate antibiotic prescription and improve AECOPD patient care. A second identical chart review for 2017 has been completed. Data analysis will be finalized prior to the conference.

Introduction: Acute atrial fibrillation (AAF) is the most common arrhythmia managed in the Emergency Department (ED). Direct costs of AAF are primarily attributed to ED visits and subsequent admission to hospital. A better understanding of patients attitudes regarding ED attendance is necessary to develop strategies to improve the patient care experience while simultaneously reducing ED presentation and inappropriate hospital admissions. This study aims to describe patient perspectives on ED use for AAF using in-depth qualitative interviews. Methods: An interview template designed to explore why patients attend the ED for AAF was constructed based on the Theoretical Domains Framework, a theory-informed approach that utilizes 14 domains to describe influencers of behavior. We conducted audio-recorded, semi-structured interviews of patients following their presentation to the ED for management of AAF. Interviews were anonymized, transcribed and imported into NVivo for coding and analysis. Two independent reviewers used a direct approach to code participant statements. Discrepancies were resolved by a third party. Belief statements were generated and relevant domains identified based on high frequency scores, conflicting belief statements or evidence of strong influencing beliefs. Results: 12 patient interviews, mean age 63.1 years, 91.7% male, 75.0% recurrent AAF, were completed. Patients stated that they attended the ED because: 1) symptom severity; 2) they were instructed by physicians to attend the ED should their AAF recur; and 3) they were encouraged by family members to attend. Their primary goal was to have relief of their symptoms. There was no expectation of specialist consultation or admission to hospital. Even though most patients stated they were open to managing these episodes independently, they reported that they did not have the knowledge or tools to do so. Conclusion: Patients with AAF present to the ED because of their symptom burden, social influences (physician and family) and lack of other management options. This study demonstrates the need for development of patient self-management strategies which will empower patients in their disease management and may decrease future ED visits.

Introduction: Trauma leading to uncontrolled hemorrhage of the torso in the critically injured patient can rapidly progress to decreased cerebral and cardiovascular perfusion and carries a significant morbidity and mortality. Given the non-compressible nature and difficult anatomic access of these injuries, obtaining hemostasis is often a challenge and non-surgical options are sparse. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a rapidly administered emergency department intervention that allows transient source control of caudal torso hemorrhage while arranging definitive surgical management. Although initially postulated in the 1950s, limited research regarding its therapeutic use in trauma has been available until recently. Here, we present a systematic review of the literature pertaining to the use of REBOA in severe trauma. Methods: An experienced medical librarian searched electronic databases for terms relating to REBOA, aortic balloon occlusion, hemorrhage, trauma and shock. Articles were identified, screened, retrieved and reviewed in accordance with PRISMA systematic review guidelines. English case reports, case series, cohort studies, randomized-controlled trials, systematic reviews and meta-analyses pertaining to the use of REBOA in human trauma patients were included. Customized inclusion and data extraction forms were created and used to form an electronic database of relevant studies. Results: After exclusion of duplicates, 2147 potentially relevant articles were identified and screened by title/abstract and 136 articles meeting inclusion criteria were retrieved for full-text review. Final analysis of 26 articles included 5 case reports, 13 case series, 7 observational cohort studies and 1 systematic review. Data spanning 771 patients undergoing REBOA were collected (weighted average age: 49.5, gender: 67.7% male, injury severity score: 35.1). Where data available, REBOA increased systolic blood pressure by a weighted average of 54.7mmhg and overall survival was 32.6%. Conclusion: Limited evidence pertaining to the use of REBOA in severe trauma exists with the majority of available data coming from individual case studies and case series. By extension, quantitative analysis regarding outcome data of this intervention requires further research in the form of larger studies with subgroup analysis to identify the subset of patients for which REBOA may benefit and to further delineate the risks of implementing this intervention

Introduction: Emergency departments (ED) across Canada acknowledge the need to transform in order to provide high quality care for the increasing proportion of older patients presenting for treatment. Older people are more complex than younger ED users. They have a disproportionately high use of EDs, increased rates of hospitalization, and are more likely to suffer adverse events. The objective of this initiative was to develop minimum standards for the care of older people in the emergency department. Methods: We created a panel of international leaders in geriatrics and emergency medicine to develop a policy framework on minimum standards for care of older people in the ED. We conducted a literature review of international guidelines, frameworks, recommendations, and best practices for the acute care of older people and developed a draft standards document. This preliminary document was circulated to interdisciplinary members of the International Federation of Emergency Medicine (IFEM) geriatric emergency medicine (GEM) group. Following review, the standards were presented to the IFEM clinical practice group. At each step, verbal, written and online feedback were gathered and integrated into the final minimum standards document. Results: Following the developmental process, a series of eight minimum standard statements were created and accepted by IFEM. These standards utilise the IFEM Framework for Quality and Safety in the ED, and are centred on the recognition that older people are a core population of emergency health service users whose care needs are different from those of children and younger adults. They cover key areas, including the overall approach to older patients, the physical environment and equipment, personnel and training, policies and protocols, and strategies for navigating the health-care continuum. Conclusion: These standards aim to improve the evaluation, management and integration of care of older people in the ED in an effort to improve outcomes. The minimum standards represent a first step on which future activities can be built, including the development of specific indicators for each of the minimum standards. The standards are designed to apply across the spectrum of EDs worldwide, and it is hoped that they will act as a catalyst to change.

Introduction: Our study objectives were to assess the acceptability of using the emergency department (ED) waiting room to provide knowledge on, and offer opportunities for organ and tissue donor registration; and to identify barriers to the donor registration process in Ontario. Methods: We conducted a paper based in-person survey over nine days for eight hour blocks in March and April 2017. The survey instrument was created in English using existing literature and expert opinion, pilot tested and then translated into French. The study collected data from patients and visitors in an urban academic Canadian tertiary care ED waiting room. All adults in the waiting room were approached to participate during the study periods. Individuals waiting in clinical care areas were excluded, as well as those who required immediate treatment. Results: The number of attempted surveys was 324; 67 individuals (20.7%) refused to partake. A total of 257 surveys were distributed and five were returned blank. This gave us a response rate of 77.8% with 252 completed surveys. The median age group was 51-60 years old with 55.9% female. Forty-six percent were Christian (46.0%) and 34.1% did not declare a religious affiliation. Nearly half of participants (44.1%) were registered organ donors. The majority of participants agreed or were neutral (83.3%) that the ED waiting room was an acceptable place to provide information on organ and tissue donation. Further, 82.1% agreed or were neutral that the ED was an acceptable place to register as an organ donor. Nearly half (47.2%) agreed that they would consider registering while in the ED waiting room. A number of barriers to registering as an organ and tissue donor were identified. The most common were: not knowing how to register (22.0%), a lack of time to register (21.1%), and having unanswered questions regarding organ and tissue donation (18.7%). Conclusion: Individuals waiting in the ED are supportive of using the ED waiting room for distributing information regarding organ and tissue donation, and facilitating organ and tissue donation registration. Developing such a practice could help to reduce some of the identified barriers, including a lack of time and having unanswered questions regarding donation.

Introduction: Endotracheal intubation is frequently used in emergency departments and is often life saving, but it is also known to cause adverse events that can potentially lead to death. The main objective of this study is to evaluate mortality rates and duration of hospitalisation in patients who experienced post-intubation hypotension (PIH). Methods: A historical cohort of patients admitted between 07/2011 and 11/2014 at the ED of a level-one trauma centre. Patients were included if they were aged 16 years old or more, were intubated in the resuscitation room,had less than 3 intubation attempts, no need of surgical airway access, and had recorded vital signs prior to intubation. All clinical data including vitals were prospectively collected using ReaScribe®. PIH was defined by one measure or more of systolic arterial blood pressure <90 mm Hg. We retrospectively analysed the occurrence of PIH at 4 time points : 5, 15, 30 minutes, and at any moments after intubation. Study outcomes were in-hospital death and hospital length of stay in days (LOS). Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: 261 patients were included in the analyses. Amongst patient who experienced PIH, incidence of mortality was, respectively for each time estimate, of 31,0%, 33,3%, 28,6% and 26,9 % compared to 25,4% (p=0,5), 24,2% (p=0,1), 24,9% (p=0,5), and 25,4 % (p=0,8) in the normotensive group. The mean duration of hospitalisation in the group exposed to PIH was respectively of 26 (12,9-53,3), 22 (13,5-35,5), 19 (13,6-27,8), and 18 days (13.5-24.8) compared to 15,6 (12,9-18,9), 15,4 (12,6-18,8), 15,3 (12,3-19,1), and 15,5 (12.1-19.7) days (p=0,4). Conclusion: There was no association between the presence of post-intubation hypotension at 4 different time estimates and the in-hospital mortality nor the hospital length of stay. Further evaluation in specific sub-group should be foreseen to prevent adverse events from endotracheal intubation.

Introduction: It is estimated that up to 30% of medical services in Canada are potentially unnecessary, not supported by current evidence or may cause patient harm. This type of practice negatively impacts patients and the healthcare system. Evidence suggests that medical education strongly impacts resource utilization in future practice. Our objective was to integrate Choosing Wisely (CW) recommendations into the undergraduate medical education curriculum to improve students understanding of resource stewardship in their pre-clerkship training. Methods: Post-course survey data and written feedback were collected from the Cumming School of Medicines 2019 class. Qualitative analysis of written feedback was used to identify perceived strengths and areas of improvement to inform additional changes for the 2020 class through a Plan-Do-Study-Act (PDSA) cycle. Results: The post-course survey was completed by 143 students. 60% reported the inclusion of CW improved their ability to develop a clinical management plan. Using the information gathered from the qualitative analysis, we made the following changes for the 2020 class: create an introductory lecture on resource stewardship, incorporate relevant CW recommendations into case study learning objectives, and create standardized slides on CW recommendations for lecturers. Feedback from the 2020 class revealed that the changes were well received and students reported feeling more comfortable with resource stewardship concepts. Conclusion: This data reveals that our efforts have increased students confidence in creating a management plan that integrates resource stewardship and patient safety, and elicited strong faculty support. We will continue to integrate these changes and to obtain student and faculty feedback to help inform additional iterative changes for the subsequent cohort. Our findings are valuable for other medical schools across Canada seeking to incorporate CW material.

Introduction: Hypertension is common and a major cause of morbidity and mortality. Because it is asymptomatic, its diagnosis is often delayed. For many Canadians the Emergency Department (ED) is the only point of entry to the health care system, and therefore the recognition of undiagnosed and untreated hypertension in the ED is increasingly important. This study sought to evaluate the prevalence and severity of hypertension in patients presenting to Calgary area EDs, as well as to determine whether medical therapy was initiated and if patients had primary care providers for follow-up. Methods: Multi-centre electronic medical record (EMR) review of all adult patients presenting to Calgary area EDs from January 1, 2016 to December 31st, 2016. Hypertension was coded electronically by triage nurses and defined as systolic blood pressure SBP 140 mmHg and/or diastolic blood pressure DBP 90 mmHg. Hypertensive urgency was defined as SBP 180 mmHg and/or DBP 120 mmHg. Descriptive data was used to show patient demographics and hypertension prevalence. Primary care provider status, previous diagnosis of hypertension, chief complaint, and ED diagnoses were extracted and the EMRs were manually searched to determine whether treatment was initiated in the ED. Results: Of 304392 patients presenting to all Calgary sites, 43055 (14%) were found to have hypertension; mean age 52 (range 18 to 104), female 42%. Of these, 32986 (77%) had no known previous hypertension and 31% lacked a primary care provider. 0.2% had documentation of treatment initiated in the ED. 16% met criteria for hypertensive urgency. Conclusion: Many patients presenting to the ED have hypertension, often previously undiagnosed and at times severe. Many lack access to primary care. EDs may play an important role in the early recognition of hypertension. Dedicated management and follow-up pathways are indicated for this high-risk population.

Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Microskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Surgical cricothyrotomy is a rarely performed safety critical task. Methods: Two doctors and three nurses developed stepwise team microskills checklists from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 30 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. Commonly available airway trainers were retrofitted with the 3-D printed larynx. The microskills checklist was used in four phases: 1. Group discussion of each microskill step; 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback - changes are recorded; 3. Total task run through without interruption - changes are recorded; 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 12/21, RNs 6/12. The commonest changes in practice were equipment preparation (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 5/5). Conclusion: Microskills checklists facilitate cricothyrotomy skill development in interprofessional teams in this provisional analysis.

Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.

Introduction: Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about the patient condition, stability, the operational environment and an appropriate clinical course. The Situational Awareness Global Assessment Tool (SAGAT) is a validated tool for measuring situational awareness. The SAGAT tool was measured during a series of standardized high fidelity advanced airway management simulations in multidisciplinary teams in New Brunswick Emergency Departments delivered by two simulation programs Methods: Thirty eight simulated emergency airway cases were performed in situ in Emergency Departments and in learning centers in Southern New Brunswick from September 2015 to October 2017. Eight standardized cases were used whose educational objectives were to develop the optimization of critically ill patients prior to induction, to deliver patient-centered anesthesia and to choose an appropriate airway strategy. Learner profiles collected. Cases were divided into two groups; those that contained critical errors and those that did not based on video assessment. Critical errors were defined as failure of 1) Oxygenation 2) Shock correction 3) Induction dose estimation 4) Choice of airway management paradigm. The SAGAT has a maximum score of 13 and was assessed by research nurses after each case for all participants. SAGAT scores were non-normally distributed, so results were expressed as medians with interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. Results: Results. Of the 38 cases, 14 contained one more critical errors. The median SAGAT score in the group that contained critical errors was 8 +/− 2 (IQR). The median SAGAT Score in the group that contained no critical errors was 11 +/− 2 (IQR). The median scores we significantly different with a p-value of 0.02. Conclusion: In this study in simulated emergency cases, higher SAGAT scores were associated with teams leaders that did not commit safety critical errors. This work is the initial analysis to develop standards for Simulated team performance in Emergency Department teams.

Introduction: We sought to characterize the management of uncomplicated subcutaneous abscesses (SA) by Canadian emergency physicians (EPs). Methods: Cross-sectional study of CAEP membership. Subjects were emailed an invitation to an online survey, and two biweekly reminders. Wilcoxon rank sum test was used for association with age, and Chi Square and Fischers exact test were used for binary variables. Results: Response rate was 21.2 % (392 Reponses / 1850 surveyed). Duration of practice ranged from 30.2 % practising <= 5 years, to 25.7% practising >= 20 years. Teaching setting was described in 89.1% of responses. Irrigation with saline is performed by 57.1 % of EPs, tap water 2.1 %, or disinfectant 2.1% of EPs, with 39.1% not doing any irrigation. Approximately half (49.2%) typically do not pack or close wounds, while 40.6 % employ ribbon or gauze packing, and 1.6 % primary closure. Antibiotics are generally not prescribed by 16.8%. EPs prescribe antibiotics when suspecting surrounding cellulitis (84.2%), immunocompromised host (51.6%), MRSA (28.9%), or recurrence within 30 days (27.5 %). Cultures are taken almost always by 28.2%, half the time or less by 33.9%, never by 11.6%, and if MRSA is suspected by 33.9%. Follow-up instructions are with FP (56.7%), ED at 24 hours (5.91 %) or 48 hours (17.74 %), or not required (24.7%). Most EPs (90.9%) report having no standardized protocol for abscess management in their ED. EPs with fewer years in practice are more likely to make cruciate incisions (p=0.009), to generally not irrigate incisions (p=0.02), to culture if MRSA is suspected (p=0.02), and to prescribe antibiotics when suspecting MRSA (p=0.02) immune-compromised host (p=0.03), and in case of spontaneous treatment failure or recurrence (p=0.0004). EPs with more years in practice are more likely to pack with ribbon gauze (p=0.06), and to almost always swab for C&S (p=0.04) Conclusion: Practice variability and deviations from practice guidelines (i.e. IDSA, Choosing Wisely Canada) are noted. A knowledge translation exercise based on the guidelines for Canadian EPs would be useful.

Introduction: Increase in functional decline of older adults after discharge from the emergency department (ED) has been reported; however, evaluations of interventions to mitigate this problem are infrequent. Data collected in the ED on older adults may document functional status, yet their utility for research is unknown. This study aimed to assess the usability of data collected by ED Transition Coordinators (EDTC) during routine assessments for functional decline research. Methods: EDTCs assess all patients 75 years old presenting to the ED and complete a standardized Transitional Assessment Referral (TAR) form that documents patients independence and daily functioning. To measure the utility of these forms for research purposes, trained research staff evaluated the TARs completed in April 2017 by TCs in the University of Alberta Hospital ED by extracting data from the TARs into a purpose-built REDCap database. Researchers selected and assessed for completeness and clarity the following variables unique to the TARs: facility vs. non-facility living, goals of care and personal directive, fall history, falls in the past 90 days, independence in 14 activities of daily living (ADLs)/instrumental activities of daily living (IADLS), community services in place, and homecare referrals for discharged patients. The proportion of TARs with data for each variable and the proportion of forms with unambiguous responses in each section are reported. Results: Overall, 500 forms were analysed; patients were 41% male with a mean age of 82 (SD=11.2). Homecare referrals, facility vs. non-facility living, and independence with 14 ADLs/IADLs were the most frequently documented variables (81%, 78%, and 79%, respectively); however for ADLs/IADLs, 59% of the 79% had one or more missing components. While fall history was reported in 301 forms (60%), only 107/301 (36%) reported the number of falls in the last 90 days. The referral to homecare variable was complete in 217/268 (81%) forms; however, 99% of files were missing data about goals of care, personal directives, and receipt of community services. Conclusion: Although some information on elderly patients is consistently reported, many of the social service/human factors associated with functional decline are not recorded. While data on the TARs may be useful for studying functional decline in the ED, exploring the barriers to form completion may improve adherence thereby increasing their research utility.

Introduction: Emergency Department (ED) Transition Coordinators (TC) have been introduced to many EDs. In Alberta, the EDTC role was designed to evaluate the home needs of senior patients (75 years of age) to enable safe return home after an ED visit, thereby mitigating admissions and return ED visits. The effectiveness of this role at achieving its objectives has received limited evaluation. Methods: TCs assess all ED patients 75 years old, and physicians request TC assessment for patients <75 years. The TC assessment includes completing a Transitional Assessment Referral (TAR) form that collects information on comorbidities, living arrangements, connections to community and homecare services, independence in activities of daily living (ADLs), and referrals, and disposition. Trained research staff extracted data from consecutive TARs for patients presenting during April 2017 into a REDCap database. The proportions of patients seen by TCs who were admitted, had an unplanned return to the ED within the study period, or received a new homecare referral were assessed. Categorical variables are reported as proportions; continuous variables are reported as mean and standard deviation (SD) or median and interquartile range (IQR), as appropriate. Results: In April 2017, there were 9849 visits to the ED; of these, TCs assessed 478 patients during 500 visits. The mean age was 82 (SD=11.2) and 41% were male; 22 patients presented twice during April 2017. Patients had a median of 2 (IQR: 1, 5) co-morbidities and 40 (8%) patients reported falls in the past 90 days (median=1; IQR: 1, 2). Overall, 144 (29%) patients lived in a care facility, while 204 (41%) lived at home; residence was unclear or not documented for 152 (30%). Patients reported being independent in a median of 9/14 (IQR: 3, 13) ADLs. An existing homecare connection or receipt of homecare services was documented for 185 patients (37%). Finally, 59 (12%) visits included a new or updated homecare referral, while 200 (33%) ED visits ended in admission. Conclusion: Elderly patients seen in the ED assessed by EDTCs are complex, and despite being well connected, they frequently need hospitalization. In a small proportion of cases, additional or new home care resources are required prior to ED discharge; however, few patients returned to the same ED during the one month study period. Given the high proportion of patients assessed, further evaluation of outcomes is warranted.

Introduction: Introduction: Transitions in care (TiC) interventions have been proposed to improve the management and outcomes of patients in emergency departments (ED). The objective of this review was to examine the effectiveness of ED-based TiC interventions to improve outcomes for adult patients presenting to an ED with acute atrial fibrillation or flutter (AFF). Methods: Methods: A comprehensive search of eight electronic databases and various grey literature sources was conducted. Comparative studies assessing the effectiveness of interventions to improve TiC for patients presenting to the ED with acute AFF were eligible. Two independent reviewers completed study selection, quality assessment, and data extraction. When applicable, relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity was reported among studies using I-square (I2) statistics. Results: Results: From 744 citations, seven studies were included, consisting of three randomized controlled trials (RCT), three before-after (B/A) studies, and one cohort study. Study quality ranged from unclear to low for the RCTs according to the risk of bias tool, moderate in the BA trials according to the BA quality assessment tool, and high quality of the cohort study according to the Newcastle Ottawa scale. The majority of interventions were set within-ED (n=5), including three clinical pathways/management guidelines and two within-ED observation units. Post-ED interventions (n=2) included patient education and general practitioner referral. Four studies reported a decreased overall hospital length of stay (LoS) for AFF patients undergoing TiC interventions compared to control, ranging from 26.4 to 53 hours; however, incomplete and non-standardized outcome reporting precluded meta-analysis. An increase in conversion to normal sinus rhythm among TiC intervention patients was noted, which may be related to increased utilization of electrical cardioversion among the RCTs (RR=2.16; 95% CI: 1.42, 3.30; I2=%), B/A studies (RR=2.69, 95% CI: 2.17, 3.33), and cohort study (RR=1.39; 95% CI: 1.24, 1.56). Conclusion: Conclusions: Within-ED TiC interventions may reduce hospital LoS and increase use of electrical cardioversion. However, no clear recommendations to implement such interventions in EDs can be generated from this systematic review and more efforts are required to improve TiC for patients with AFF.

Introduction: Emergency medicine clinicians (physicians, nurses, paramedics, physician assistants) utilize podcasts for learning. However, their versatility produces variability in the ways they are used (e.g. their speed can be increased or decreased, unrelated activities can be performed simultaneously, or they can be accompanied by active learning methods). This study investigated how and why podcasts are used by an international cohort of clinicians. Methods: An international sample of medical students, residents, physicians, nurses, physician assistants, and paramedics was recruited to complete a survey hosted on FluidSurveys software using social media (Twitter and Facebook), direct contact from our international authorship group, infographics, and a study website (https://METRIQstudy.org/). Participants who indicated interest in the study were sent an email containing the study survey. Reminder emails were sent every 5-10 days a maximum of three times. Results: 462 clinicians expressed interest and 397 completed the survey (86.0% completion rate). Participants hailed from 34 countries (38.8% Canada, 30% United States, 31.2% outside of North America) and a majority (61.9%) were physicians. Approximately half (45.8%) of the participants listened to podcasts weekly. Podcasts were used to learn core material (75.1%), refresh memory (72.3%), or review new literature (75.8%). Most listened on iPhones (61%) and the native Apple App (66.1%). The preferred Android apps were Pocket Casts (22.8%) and Google Play (18.5%). Many listened to podcasts while driving (72.3%). Active learning techniques such as pausing, repeating segments, taking notes, or listening to a podcast more than once were rarely used (1/4 of the time or less) by the majority of participants. Conclusion: This study describes how and why medical education podcasts are used by emergency medicine clinicians and should inform both podcast producers and future research investigating the impact of various listening habits on retention. Further analysis of the data will elucidate differences in listening habits

Introduction: A fundamental hemodynamic parameter, the central venous pressure (CVP) is rarely available in the emergency patient due the delay and risks inherent to central vein cannulation. Recently, two non-invasive strategies have emerged: a) point-of-care ultrasound to supplement traditional inspection the internal jugular waveform ; or b) near-infrared spectroscopy (NIRS) of the external jugular vein. Methods: Five medical students underwent standardized training on both NIRS device (Venus 2000 CVP; Mespere Life Sciences, Waterloo ON) and ultrasound-assisted CVP assessment. During prescheduled, randomly permuted and balanced shifts, a pair of students obtained blinded independent measurements using each device within 10 minutes of each other. High priority subjects likely to have abnormal CVP (e.g. vomiting, dehydrated, heart failure, sepsis) were approached preferentially, followed by a convenience sample of other eligible patients in the emergency department. Secondary outcomes were stopwatch-recorded time from device ready to stable measurement, as well as operator ease, operator confidence and patient discomfort. The blinded treating physician rated each subjects volume status on an ordered scale: depleted, neutral and overloaded. Results: We enrolled 104 patients (median [IQR] age 68 [53, 78] years; 50% male; BMI 27.6 [17.0, 47.7] kg/m2; admission rate 27%) in June-August 2017. Treating physicians classified 17 as volume depleted and 12 overloaded. CVP measurements differed widely between techniques: ultrasound 8 [7, 9] cmH2O (3 cases unobtainable) vs NIRS 12 [8, 17] cmH2O (13 unobtainable). Agreement and correlation between the two devices was extremely low (R2=0.04). While neither technique demonstrated a strong association with the treating physicians estimate of volume status, only the ultrasound values increased monotonically with physician estimate. With regards to secondary outcomes, ultrasound measurements took less time (paired difference 50 seconds [95% CI 7, 93]), and operators were more confident (0.63 [0.02, 1.23] out of 10) and at ease (0.78, [0.13, 1.43]) with ultrasound; patients rated discomfort equally (-0.06 [-0.30, 0.18]). Conclusion: Non-invasive measurement of CVP remains a challenge in the emergency department. The external jugular pressure by NIRS has very high variability and poor agreement with ultrasound-enhanced inspection of the internal jugular, suggesting that this technique is not yet practical for use by non-experts.

Introduction: Emergency department (ED) providers are frequently challenged with how best to treat acute pain in older patients, specifically when non-opioid analgesics are insufficient or contraindicated. Studies have documented older patients presenting to the ED with painful conditions are less likely to receive pain medications than younger patients, and this inadequate pain control has been associated with increased risk of delirium and longer hospital stays. As there are no guidelines informing best practice of analgesia in the older adult population, emergency physicians often report uncertainty regarding the ideal choice of opioid analgesic. The objective of this study was to compare the efficacy of opioid analgesics for acute pain in older adults (70 years) in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing the efficacy of 2 or more opioid analgesics for acute pain in older patients (70 years) in ambulatory settings (i.e., EDs, clinics) were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Results: After screening titles and abstracts of 1297 citations, the full-texts of 63 studies were reviewed, and 1 study met the inclusion criteria. This study allocated patients to receive either single dose of 0.0075-mg/kg IV hydromorphone versus 0.05-mg IV morphine and found no clinical or statistical difference between the two treatments in older adults presenting to an urban academic ED with acute, severe pain. Conclusion: The lack of published research in this area demonstrates a significant gap in the existing knowledge of the comparative efficacy of opioid analgesics in this growing patient population and that well-designed RCTs are urgently needed.

Introduction: Anaphylaxis is a life-threatening condition that paramedics are equipped to treat effectively in the field. Current literature suggests improvements in paramedic recognition and treatment of anaphylaxis could be made. The aim of this study was to compare the proportion of cases of anaphylaxis appropriately treated with epinephrine by paramedics before and after a targeted educational intervention. Methods: This was a retrospective medical records review of patients with anaphylaxis managed by primary or advanced care paramedics in five Emergency Medical Service areas in Ontario, before and after an educational module was introduced. This module included education on anaphylaxis diagnosis, recognition, treatment priorities, and feedback on the recognition and management from the before period. All paramedic call records (PCRs) coded as local allergic reaction or anaphylaxis during 12-month periods before and after the intervention were reviewed by trained data abstractors to determine if patients met an international definition of anaphylaxis. The details of interventions performed by the paramedics were used to determine primary and secondary outcomes. Results: Of the 600 PCRs reviewed, 99/120 PCRs in the before and 300/480 in the after period were included. Of the charts included, 63/99 (63.6%) in the before and 136/300 (45.3%) in the after period met criteria for anaphylaxis (p=0.002). Of the cases meeting anaphylaxis criteria, 41/63 (65.1%) in the before and 88/136 (64.7%) in the after period were correctly identified as anaphylaxis (p=0.96). Epinephrine was administered in 37/63 (58.7%) of anaphylaxis cases in the before period and 76/136 (55.9%) in the after period (p=0.70). Anaphylactic patients with only two-system involvement received epinephrine in 20/40 (50.0%) cases in the before period and 45/93 (48.4%) in the after period (p=0.86). Conclusion: There are gaps in paramedic recognition and management of anaphylaxis, particularly in cases of two-system involvement. These gaps persisted after the implementation of an educational intervention. Other quality interventions and periodic refreshers may be necessary to improve prehospital treatment of anaphylaxis. Limitations include an increase in overall cases and decrease in rate of true anaphylaxis in the after period, which may relate to better case identification after electronic PCR implementation and changes in paramedic recognition.