Introduction: As the baby-boomer generation ages, the number of elderly patients with complex health issues visiting emergency departments (EDs) will continue to increase. Evidence suggests elderly patients often have better health outcomes if they can be managed at home with appropriate community and primary care supports in place, rather than being admitted to hospital. ED2Home is a program that launched March 1, 2016 in the Nanaimo Regional General Hospital (NRGH) ED. It aims to assess admitted patients aged 70 and over and discharge them with community supports and follow-up. The aim of this Quality Improvement project was to evaluate how many patients were successfully discharged by the ED2Home program in its first few months, and to characterize which patients were more likely to be successfully discharged versus bounce back to the ED. Methods: This Quality Improvement project audited the charts of 87 patients discharged by ED2Home from June-Sept 2016. Variables examined included the following: age, gender, chief complaint, mobility status, living situation, which ED2Home health care provider (RN vs MD) to facilitate discharge, whether patient had a family physician, and resources used (ex. pharmacy, physiotherapy, occupational therapy, etc.) to help facilitate discharge. Our evaluation was conducted by means of a retrospective chart review. Descriptive statistics were derived for variables of interest. Results: There were 87 patients discharged home by the ED2Home whose charts were reviewed. 48 (55%) of these patients were successfully discharged home without revisit to the NRGH ED within 30 days of discharge. 29 patients returned to the NRGH ED within 30 days of original discharge for the same original chief complaint. Patients successfully discharged were similar to those who bounced back in terms of gender and mean age. Patients who bounced back to the ED were more likely to have chief complaints of dyspnea and confusion compared to those successfully discharged. Patients who were successfully discharged had a higher proportion of patients with social admissions compared to those who bounced back to the ED within 30 days. A higher proportion of patients successfully discharged had been evaluated by the ED2Home physician (versus nursing alone) compared to patients who bounced back within 30 days. Conclusion: ED2Home appears to be successful at discharging patients and preventing revisit to the ED and re-hospitalization, similar to other transitional programs for the elderly that have been reviewed in the literature. Patients presenting with more complex issues, such as dyspnea and confusion, may not be as suitable for rapid discharge from the ED through this program as patients presenting with issues helped by additional allied health care supports, such as failure to thrive/social admission. Additional Quality Improvement iterations of the ED2Home program should be undertaken in the future, using these suggestions.

Introduction: As reported by the Canadian Institute for Health Information, the rate of child and youth emergency department (ED) visits for mental health complaints increased by 50% between 2007 and 2015. Improving care for these patients has been identified as a major priority of Alberta Health Services As part of a multi-phased approach to improving care, the Emergency and the Addiction and Mental Health Strategic Clinical Networks undertook an analysis of administrative data to define incidence in Alberta and changing trends. Methods: The data analyzed included 5 different clinical information systems encompassing the 17 highest volume hospitals in Alberta, from April 2013 to March 2016. Patient encounters were included if the patient was under 25 years of age at the time of visit, and if the encounter included a CEDIS Presenting Complaint and/or an ICD-10 Primary Diagnosis relating to Addiction and/or Mental Health (AMH). A total of 54,810 patient encounters were included. Data was analyzed using descriptive statistics. Sub-group analysis was undertaken based upon age, presenting complaint, and primary diagnosis. Results: The incidence of children and youth presenting to an ED with an AMH complaint and an AMH primary diagnosis increased 22% and 7%, respectively, from 2013/14 to 2015/16. Admissions of patients were constant throughout this period. The largest increase in ED visits occurred among children aged 7-10, with a 60% increase in visits defined by presenting complaint and a 21% increase in primary diagnosis. The second largest increase was in young adults aged 18-21 with a 26% increase defined by presenting complaint, and a 12% increase in primary diagnosis. Analyzed by age group, the largest increase in primary diagnosis between 2013/14 and 2015/16 was seen in Depression/Suicidal/Self Harm with a 667% increase among ages 0-6, and a 79% increase among ages 7-10. The second highest increase was for Anxiety/Situational Crisis with a 223% increase among ages 0-6, and 74% among children aged 7-10. Conclusion: Within Alberta there has been a substantial increase in the incidence of child and youth visits to the ED for issues of mental health and addictions. It is clear is that these changing trends are placing an increased burden on our healthcare system and necessitate strategic planning to ensure the health and wellness of our patients.

Introduction: The specialist Emergency Medicine (EM) postgraduate training program at Queens University implemented a new Competency-Based Medical Education (CBME) model on July 1 2017. This occurred one year ahead of the national EM cohort, in the model of Competence By Design (CBD) as outlined by the Royal College of Physicians and Surgeons of Canada (RCPSC). This presents an opportunity to identify critical steps, successes, and challenges in the implementation process to inform ongoing national CBME implementation efforts. Methods: A case-study methodology with Rapid Cycle Evaluation was used to explore the lived experience of implementing CBME in EM at Queens, and capture evidence of behavioural change. Data was collected at 3- and 6- months post-implementation via multiple sources and methods, including: field observations, document analysis, and interviews with key stakeholders: residents, faculty, program director, CBME lead, academic advisors, and competence committee members. Qualitative findings have been triangulated with available quantitative electronic assessment data. Results: The critical processes of implementation have been outlined in 3 domain categories: administrative transition, resident transition, and faculty transition. Multiple themes emerged from stakeholder interviews including: need for holistic assessment beyond Entrustable Professional Activity (EPA) assessments, concerns about the utility of milestones in workplace based assessment by front-line faculty, trepidation that CBME is adding to, rather than replacing, old processes, and a need for effective data visualisation and filtering for assessment decisions by competency committees. We identified a need for administrative direction and faculty development related to: new roles and responsibilities, shared mental models of EPAs and entrustment scoring. Quantitative data indicates that the targeted number of assessments per EPA and stage of training may be too high. Conclusion: Exploring the lived experience of implementing CBME from the perspectives of all stakeholders has provided early insights regarding the successes and challenges of operationalizing CBME on the ground. Our findings will inform ongoing local implementation and higher-level national planning by the Canadian EM Specialty Committee and other programs who will be implementing CBME in the near future.

Introduction: Despite clear health benefits, and Public Health Agency of Canada recommendations, vaccination rates among Canadian adults are low. Frequent patient contacts, wait times, and the availability of trained staff make the emergency department (ED) a potential location to target specific populations and administer vaccinations. We evaluated the feasibility of two strategies to administer the Tdap vaccine to adult patients presenting to a single referral ED. Methods: Two immunization strategies and a control group were randomly ordered from one to three. Data collection for group one started on study day one with data collection for groups two and three on study days two and three respectively. This sequence was repeated over 15 consecutive weekdays (Monday-Friday, 0730-1530), evenly assigning each group to 5 different days. On intervention days, adult patients were screened during the triage process for eligibility to receive the Tdap vaccine. An ED based (EDB) strategy offered patients vaccination during that visit. The second strategy offered eligible patients a public health referral (PHR) to receive the vaccine at a later date. On all study days, patient triage times (TT), as well as markers of ED efficiency (number of patient registrations, time to physician, length of stay, left without being seen, number of admissions, number of boarded patients) were recorded. Results: The primary outcome, the proportion of eligible adults immunized, was significantly higher at 66% (n=81) for the EDB strategy (228 screened, 122 eligible), compared with 21% (n=20) for the PHR strategy (217 screened, 94 eligible; x2 (2, n=216)=43.41, p<0.00001). In addition, 10 participants in the PHR group received a second vaccine (Pneumococcal (7), Influenza (2), Human Papillomavirus (1)). Reasons for vaccine ineligibility included having an up-to-date Tdap (EDB n=47 (21%), PHR n=46 (21%)) and being considered in too much distress by the triage nurse (EDB n=26 (11%), PHR n=19 (9%)). Triage time was less for the control group (M=5:55 [mins:secs], SD=2:48) than for the EDB (M=6:47, SD=3:12) and PHR (M=7:25, SD=2:45) strategies. Conclusion: An ED based screening and immunization strategy was highly effective in providing eligible adult patients with the Tdap vaccine. A resulting small increase in triage time was not clinically significant. Further studies are required to generalize these results.

Introduction: Ultrasound-guided intravenous (UGIV) insertion performed by nurses has been shown to be more effective than the blind approach for patients with difficult intravenous (IV) access in the emergency department (ED). While both the single-operator (SO) (where a single operator holds the IV and probe) and dual-operator (DO) (where a second operator holds the probe) techniques have been described, the DO is more resource-intensive, requiring a second operator to be present. The objective of this study is to compare the first-attempt cannulation success rates between a SO and DO technique in ED patients with predicted difficult access. Methods: We conducted a randomized controlled non-inferiority trial using a convenience sample of adult ED patients. Participating ED nurses received a one-hour UGIV training session including didactic and practical training on simulated arms. Patients were enrolled if they met any of three criteria for difficult access: (1) history of difficult access, (2) no visible or palpable veins, or (3) two failed blind attempts. Patients requiring active resuscitation, lack of suitable veins on US, or those unable to consent or comply with the procedure were excluded. Eligible patients were randomized to the SO or DO technique and a maximum of two UGIV attempts were allowed. The primary outcome was first-attempt success rate. Additional outcomes included overall success rate, number of attempts, time to successful cannulation, patient pain scores, operator ease of use scores, and complications 30 minutes after insertion. The chi-square test was used to compare success rates between groups and t-tests used for all other secondary outcomes. Results: 42 eligible patients have been approached for our study. 14 were excluded due to lack of visible veins on US or due to ongoing resuscitation. A total of 33 UGIV attempts were performed on 28 patients (17 in SO group, 16 in DO group). There was no statistically significant difference in first attempt success rates between the SO group of 76.5% (95% CI [50.1% to 93.2%]) and the DO group of 68.8% (95% CI [41.3% to 89%]) (p=0.62). There were also no statistically significant differences between the SO and DO groups in time to cannulation (140 vs 165 seconds, p=0.36), patient preference on a 10-point scale (7.0 vs 7.9, p=0.49), patient pain score (6.3 vs 6.6, p=0.87) or nursing ease of use (5.3 vs 6.5 p=0.23) respectively. There were no complications noted in either arm of the study. Conclusion: To date, the SO technique appears to be non-inferior to the DO technique for successful UGIV cannulation. Our results support the use of the SO technique, reducing the need for additional nursing resources when performing this procedure.

Introduction: Over the last few decades, health care facility design has been studied to look at its effect on many patient-centred outcomes. However, limited data exists on the impact that specific physical features of a clinical space may have on learning and the educational experience. The aim of this study is to develop a set of characteristics which clinicians, clinical teachers and residents believe should be present in a clinical space to maximize trainees learning, using an emergency department (ED) as a context. Methods: A qualitative methodology used semi- structured interviews with a purposive sample of twelve attending physicians and residents who work in EDs of varying age and design at several sites of a quaternary university hospital. We explored their perceptions of the physical features in the clinical and learning environment that supported or impeded teaching and learning. The interviews were transcribed and thematically analyzed. Results: Preliminary results show that many physical characteristics of the clinical space are perceived to have an impact on trainees learning experience. A design with separation between clinician-learner dyads and the patients, with a visual access; shared clinical space among different health care professionals within a reasonable distance; availability of enough clinical space for specific emergency presentations; features such as adequate size, appropriate light, and control of sound were all perceived to enhance and augment clinical learning. Not surprisingly, non-design factors such as the presence of a functioning team and the availability of adequate equipment and technology was considered as important as the characteristics of physical space to optimize learning. Conclusion: This study demonstrates the importance and the impact of physical space design on trainees learning in a dynamic clinical environment. It provides teachers and policy-makers with a basis for developing criteria of the physical characteristics of a healthcare facility to maximize learning.

Introduction: Hypertensive disorders of pregnancy (HDP), including preeclampsia, can develop or worsen in the early postpartum period, often following discharge from hospital, resulting in severe preventable maternal morbidity and mortality. Due to a lack of routine early out-patient follow-up, many women with postpartum HDP present to the emergency department (ED) with severe hypertension or symptoms of preeclampsia (e.g., headache). In the ED, postpartum HDP can be difficult for clinicians to recognize (due to vague presenting symptom) and manage (due to lower blood pressure targets and concern of medication safety). ED clinicians recognized a need for timely recognition and effective treatments for postpartum HDP in the ED to improve maternal outcomes. As such, as part of a multi-step quality improvement initiative, an interdisciplinary team developed and implemented a postpartum HDP management protocol (consisting of nursing and physician protocols and an electronic order set embedded in the electronic medical record). The aims of this specific project were to assess: 1) the use of this clinical management protocol in the ED; and 2) its impacts on clinical care. Methods: This quality improvement project used electronic medical records to identify: 1) ED visits for postpartum HDP for postpartum women ages 20-50; 2) utilization of the postpartum HDP order set; and 3) clinical care outcomes (consultation and admission). Patient population characteristics and clinical care measures were summarized with descriptive statistics and compared using a before and after design. Changes in the utilization of the protocol were assessed using run charts. Results: 540 women with postpartum HDP were seen in the four Calgary EDs in the 16-month period following protocol implementation compared with 335 women in the preceding 12 months. The protocol was used in 46% of these 540 women, and increased over the 16 month follow-up period. We found an increase in the frequency of consultation of specialists (47% to 52%) and admissions (26% to 29%) amongst these women after protocol implementation. Conclusion: This initial assessment demonstrated good uptake of a postpartum HDP management protocol including referral for consultation and admission to hospital for blood pressure management. Future steps include evaluation of the impacts of this management protocol on important patient outcomes.

Introduction: Early detection of ectopic pregnancy and careful management is critical to prevent adverse clinical outcomes, including fallopian tube rupture and future decreased fertility, in patients presenting to the ED with symptoms suggestive of ectopic pregnancy. Methotrexate therapy is widely accepted as a first line treatment of ectopic pregnancy, with success rates greater than 90% if used according to published guidelines. This study aims to determine the outcomes of pregnant women who presented to the ED with suspected ectopic pregnancy whom received methotrexate as first line treatment. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of 612 included patients, 30 (4.9%) were diagnosed with a ruptured ectopic pregnancy at the index ED visit. Of the remaining 582 patients, 256 (44.0%) were diagnosed with an ectopic pregnancy at the index ED visit, the Early Pregnancy Clinic, or a subsequent ED visit. Of these patients diagnosed with ectopic pregnancy, their initial treatments at time of discharge from the index ED visit were as follows: 102 (39.8%%) received methotrexate, 132 (51.6%) underwent expectant management, and 22 (8.6%) underwent surgical management. Of the 132 patients discharged with an expectant management plan, only 42 (31.8%) had a final outcome of expectant management; the others went on to be treated surgically or with methotrexate. Of the 165 patients treated with methotrexate at index visit or in follow-up, 30 (18.2%) went on to require surgical management with 17 (10.3%) documented as having ruptured on surgical evaluation. Clinical characteristics of patients treated with methotrexate include the following: mean age 32.8 years (SD 5.7), gestational age of 6.2 weeks (SD 1.2) and serum beta human chorionic gonadotropin level of 2702 mIU/mL (SD 8800). Conclusion: The proportion of patients receiving methotrexate as first-line treatment that resulted in rupture or required further surgical management is higher than reported literature at this institution. Further investigation is needed to determine if there was a relationship between methotrexate failure and non-adherence to recommended guidelines. Given the risk of a possible rupture, patient education of these risks is critical on discharge from the ED.

Introduction: The objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the ED where ectopic pregnancy had not yet been excluded. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes and 71 (12.9%) had other outcomes which included therapeutic abortion, molar pregnancy or resolution of HCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal US during their index ED visit, 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy. Conclusion: These results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.

Introduction: The 72-hr unscheduled return visit (URV) of an emergency department (ED) patient is often used as a key performance indicator in Emergency Medicine. Patients with unscheduled return visits and admission to hospital (URVA) may represent a distinct subgroup of URVs compared to unscheduled return visits with no admission (URVNA). Methods: A retrospective cohort study of all 72-hr URVs in adults across nine EDs in the Edmonton Zone (EZ) over a one-year period (Jan 1 2015 Dec 31 2015) was performed using ED information system data. URVA and URVNA populations were compared and a multivariable analysis identified predictors of URVA. Results: Analysis of 40,870 total URV records, including 3,363 URVAs, revealed predictors of URVA on the index visit including older age (>65 yrs, OR 3.6), fewer annual ED visits (<4 visits, OR 2.0), higher disease acuity (CTAS 2, OR 2.6), gastrointestinal presenting complaint (OR 2.2), presenting to a large referral hospital (OR 1.4), and more hours spent in the ED (>12 hours, OR 2.0). A decrease in CTAS score (increase in disease acuity) upon return visit was also a risk factor (-1 CTAS level, OR 2.6). ED crowding at the index visit, as indicated by occupancy level, was not a predictor. Conclusion: We demonstrate that URVA patients comprise a distinct subgroup of 72-hr URVs across an entire health region. Risk factors for URVA are present at the index visit suggesting that patients at high risk for URVA may be identifiable prior to admission.

Introduction: Stress has been shown to impair performance during acute events. The goal of this pilot study was to investigate the effects of two simulation-based training interventions and baseline demographics (gender, age) on stress responses to simulated trauma scenarios. Methods: Sixteen (16) Emergency Medicine and Surgery residents were randomly assigned to one of two groups: Stress Inoculation Training (SIT) or Crisis Resource Management (CRM). Residents served as trauma team leaders in simulated trauma scenarios pre and post intervention. CRM training focused on non-technical skills required for effective teamwork. The SIT group focused on cognitive reappraisal, breathing and mental rehearsal. Training lasted 3 hours, involving brief didactic sessions and practice scenarios with debriefing focused on either CRM or SIT. Stress responses were measured with the State Trait Anxiety Inventory (anxiety), cognitive appraisal (degree to which a person interprets a situation as a threat or challenge) and salivary cortisol levels. Results: Because the pre-intervention stress responses were different between the two groups, the results were analyzed with stepwise regression analyses. The only significant predictor of anxiety and cortisol responses were the residents appraisal responses to that scenario, explaining 31% of the variance in anxiety and cortisol. Appraisals of the post-intervention scenarios were predicted by their appraisals of the pre-intervention scenario and gender, explaining 73% of the variance. Men were more likely than women to appraise the scenarios as threatening. There were no differences in subjective anxiety, cognitive appraisal or salivary cortisol responses as a result of either intervention. Conclusion: Male residents, as well as those who appraised an initial simulated trauma scenario as threatening, were more likely to interpret a subsequent scenario as threatening, and were more likely to have larger subjective (anxiety) and physiological (cortisol) responses a subsequent scenario. Both CRM and SIT training were not effective in overcoming initial appraisals of potentially stressful events.

Introduction: Current guidelines recommend patients with first trimester bleeding without previously documented intrauterine pregnancy undergo urgent transvaginal ultrasound (TVUS) to exclude ectopic pregnancy. However, in Canadian practice to receive urgent TVUS, particularly out of daytime hours is difficult, if not impossible. Thus, when TVUS is not available to exclude ectopic pregnancy, providers use point of care ultrasound (POCUS) or their best clinical judgment to determine if the patient can be safely discharged home while awaiting outpatient follow-up. The objective of this study was to determine what proportion of first trimester patients presenting to a community hospital emergency department (ED) with vaginal bleeding undergo either TVUS or POCUS to exclude ectopic pregnancy. Methods: This is an ongoing retrospective chart review of pregnant women gestational age (GA) less than 20 weeks presenting to a community hospital ED (103,000 visits/year) with a discharge diagnosis of vaginal bleed, first trimester bleed, threatened abortion, spontaneous abortion, missed abortion, rule out ectopic pregnancy, and ectopic pregnancy from January 2016 - January 2017. Patients are excluded if they are diagnosed with a ruptured ectopic pregnancy during their index ED visit. To date, 98 patient charts have been reviewed. Results: Of the 98 included patients, 13 (13.3%) had a viable pregnancy, 37 (37.8%) had a spontaneous or missed abortion, 4 (4.1%) had an ectopic pregnancy, and 45 (45.9%) had unknown outcomes. Of included patients, 4 (4.1%) only had POCUS, 66 (67.4%) only had a radiologist-interpreted TVUS, and 3 (3.1%) had both POCUS and radiologist-interpreted TVUS during their ED index visits. Thus, 73 (74.5%) had either a radiologist-interpreted TVUS or ED provider-performed POCUS during their index ED visit. After their index ED visits, 2 (2.0%) patients returned with ruptured ectopic pregnancies, 1 of whom had not undergone initial US investigations. Conclusion: Although TVUS is standard of care to exclude ectopic pregnancy in patients presenting with first trimester bleeding or abdominal pain, our preliminary results show some patients are not receiving this diagnostic modality nor POCUS during their index ED visit. Particularly in a setting, such as this ED, without rapid access to an early pregnancy clinic, patients should be counselled about their risk of ectopic pregnancy at the time of ED discharge.

Introduction: The field of Clinical Informatics (CI) and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence-based healthcare system for the future. International graduate medical education programs have been challenged to ensure their trainees are provided with appropriate skills to deliver effective and efficient healthcare in an evolving environment. This study explored how international Emergency Medicine (EM) specialist training standards address training in relevant areas of CI. Methods: A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publically available, published documents outlining core content, curriculum and competencies from international organizations responsible for specialty graduate medical education and/or credentialing in EM for the United States, Canada, Australasia, the United Kingdom and Europe. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. Results: A total of 23 EM curriculum documents were included in the thematic analysis. Curricula content related to critical appraisal/evidence based medicine, leadership, quality improvement and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry and patient-centered informatics were only included in the EM curricula documents for the United States and were absent for each other organization. Conclusion: There is variation in the CI related content of the international EM specialty training standards which were reviewed. Given the increasing importance of CI in the future delivery of healthcare, organizations responsible for training and credentialing specialist emergency physicians must ensure their training standards incorporate relevant CI content, thus ensuring their trainees gain competence in essential aspects of CI.

Introduction: With the increasing volume of medical literature published each year, it is difficult for clinicians to translate the latest research into practice. Awareness is the first step of knowledge translation and journals have begun using social media to increase the dissemination and awareness of their publications. Infographics can describe research findings visually, are shared broadly on social media, and may be a more effective way to convey information. We hypothesized that infographic abstracts would increase the social media dissemination and online readership of research articles relative to traditional abstracts. Methods: In this randomized controlled trial, 24 original research articles were chosen from the six issues of the Canadian Journal of Emergency Medicine (CJEM) published between July 2016 and May 2017 (4 articles per issue). Half were randomized to the infographic and control groups within each issue. Infographic articles were promoted using a visual infographic outlining the findings of the article. Control articles were promoted using a screen capture image of each articles abstract. Both were disseminated through the journals social media accounts (Twitter and Facebook) along with the link to the selected article. Infographics were also published on CanadiEM.org. Abstract views, full text views, and the change in Altmetric score were tracked for 30 days and compared between groups. Unpaired two-tailed t-tests were used to detect significant differences. Results: Abstract views (mean, SD) were significantly higher for infographic articles (378.9, 162.0) than control articles (175.5, 69.2, p<0.001). Mean Altmetric scores were significantly higher for infographic articles (26.4, 13.8) than control articles (3.4, 1.7, p<0.0001). There was no statistically significant difference in full-text views between infographic (49.7, 90.4) and control articles (25.3, 12.3). Conclusion: CJEM articles promoted on social media using infographics had higher abstract viewership and Altmetric scores than those promoted with traditional abstracts. Although there was no difference in full-text readership, our results suggest that infographic abstracts may have a role in increasing the dissemination of medical literature.

Introduction: The management of patient flow in the emergency department (ED) is crucial for the practice of emergency medicine (EM). However, this skill is difficult to teach didactically and is learned implicitly in the latter half of residency training. To help expedite the learning process, we developed the GridlockED board game as an educational tool to simulate ED patient flow. By having junior medical trainees play this game, we believe that they will develop a greater understanding of patient flow and resource management in the ED. Additionally, since GridlockED is a cooperative game, players may also benefit by improving their communication and teamwork skills. Methods: GridlockED was developed over twenty months of iterative gameplay and review. Feedback from attending emergency physicians, residents, and medical students was integrated into the game through a Plan-Do-Study-Act (PDSA) model. Emergency medicine nurses, physicians and residents at McMaster University were recruited to play GridlockED. Each player completed a pre-survey to collect demographic data and to assess their prior experience with playing board games. All play sessions were recorded for data collection purposes. Following each game session, a member of the research team conducted an exit interview with the players to gather information about their play experience and the educational value of the game. A post-survey was also sent to each participant for further feedback. Results: Eighteen gameplay sessions were conducted from June to August 2017. A total of thirty-two participants played the game (13 emergency physicians, 15 residents, and four nurses). Overall responses to the post-gameplay survey showed that players endorsed GridlockED as a useful potential teaching tool (75%, n=24/32) and the majority felt that it had the potential to improve patient flow in the ED (56%, n=18/32). Most participants found that the game was easy to play (91%, n=27/29), and that the instructions were clear (87.5%, n=28/32). Respondents also felt that the game reflected real life scenarios (56%, n=18) and that cases reflected the types of patients that they saw in the ED (78%, n=25). Conclusion: Our results have shown an overall positive response to GridlockED, with most participants supporting it as both an engaging board game and potential teaching tool. We believe that future studies with larger sample sizes and medical students will further validate the use of serious games in medical education.

Introduction: The proliferation of unmanned aerial vehicle (UAV) technology has the potential to change the way medical incident commanders respond to mass casualty incidents (MCI) in triaging victims. The aim of this study was to compare UAV technology to standard practice (SP) in triaging casualties at a MCI Methods: A randomized comparison study was conducted with forty paramedic students from the Holland College Paramedicine Program. Using a simulated motor vehicle collision with moulaged casualties, iterations of twenty students were used for both a day and a night trial. Students were randomized to an UAV or a SP group. After a brief narrative participants either entered the study environment or used UAV technology where total time to triage completion, green casualty evacuation, time on scene, triage order and accuracy was recorded Results: A statistical difference in the time to completing of 3.63 minutes (95% CI: 2.45, 4.85, p=0.002) during the day iteration and a difference of 3.49 minutes (95% CI: 2.08,6.06, p=0.002) for the night trial with UAV groups was noted. There was no difference found in time to green casualty evacuation, time on scene or triage order. One hundred percent accuracy was noted between both groups. Conclusion: This study demonstrated the feasibility of using an UAV at a MCI. A non clinical significant difference was noted in total time to completion between both groups. There was no increase in time on scene by using the UAV while demonstrating the feasibility of remotely triaging green casualties prior to first responder arrival.

Introduction: Free Open Access Medical education (FOAM) resources have been developed using various needs assessment methods. We describe a storytelling exercise used to identify unperceived medical expert learning needs, which also resulted in the emergence of unknown learning needs within intrinsic physician roles. Methods: A FOAM curriculum was created for thrombosis based on an online needs assessment comprised of a topic listing, case scenarios, and a storytelling exercise. In the storytelling exercise, learners described i) a difficult case in thrombosis, and ii) why that case was difficult. In this qualitative description study, we performed a secondary thematic analysis of this storytelling data, coded for CanMEDS 2015 intrinsic roles. Two investigators independently coded transcripts to iteratively generate a coding framework. Results: 143 respondents completed the storytelling exercise. All responses yielded a gap in medical expertise, while 25 (17.5%) described an additional intrinsic theme. Learning needs in all six intrinsic roles were identified. The most commonly cited learning needs were in the Leader (recognizing how resource allocation impacts healthcare), Communicator (communicating expert knowledge with patients), and Collaborator (unclear communication between providers) domains. Participants who described an intrinsic learning need were primarily from emergency medicine (21/25, 84.0%). These excerpts were notable for how they expressed the complexity and affective components of medicine. Conclusion: Storytelling exercises can highlight context, attitudes, and relationships which provide depth to needs assessments. These narratives are a novel method of capturing emergent learning needs, which may be unknown to learner and faculty (Johari window). These intrinsic learning needs may ultimately be used to enrich learner-centered curricula.

Introduction: Choosing Wisely Canada has identified blood transfusions as a priority area for improving clinical appropriateness. Relevant recommendations include Dont transfuse blood if other non-transfusion therapies or observation would be just as effective. In parallel with this recommendation, the Alberta division of Towards Optimized Practice (ToP) has developed guidelines for the treatment of iron deficiency anemia (IDA) that emphasize the use of non-transfusion therapies (i.e. parenteral or oral iron, in appropriate patients). Choosing Wisely also emphasizes strategies to better engage patients in shared decision making. Methods: In order to better engage patients in shared decision making about their treatment options, both physician and patient handouts were developed using an iterative process. The development of the patient-facing documents began with a synthesis of educational materials currently available to patients with IDA. Clinical leaders from nine different specialties (Emergency Medicine, Family Medicine, Day Medicine, Hematology, and others) were continually engaged in the development of content using a consensus model. A focus group of ESCN patient advisors was assembled to review materials with an emphasis on: (1) Are the patient materials easily understood? (2) Are intended messages resonating while avoiding unintended messaging? (3) What information do patients require that has not been included? Following the focus group, revisions were made to patient materials and a subsequent online survey confirmed that the final version addressed any issues they had raised. Results: A four-page patient handout/infographic was developed utilizing best practices in information design, and in physician and patient engagement. Content includes the causes and symptoms of IDA, progressive treatment options from dietary changes to transfusion, and the four Choosing Wisely questions to discuss with your doctor. Conclusion: Patient education materials can be developed according to best practices in information design and stakeholder engagement. Patient focus groups demonstrate that such materials are easier to understand, and better equip patients to engage in shared decision making.

Introduction: Foreign patients often do not receive appropriate treatment in the emergency room as compared to locals. This is due to various causes such as language, insurance, and cultural differences. The purpose of this study was to investigate whether there is a wide range of health inequalities among foreigners who visited the emergency room with injury and to find out what causes it. Methods: We analyzed clinical data from the National Emergency Department Information System(NEDIS) database, which visited the emergency room from January 1, 2013 to December 31, 2015, in all age groups. Foreigners are classified based on the personal information described in the NEDIS. We analyzed the number of injuries, serious cases(death, operation, ICU admission), length of stay in ER, and transfer ratio. Results: A total of 4,464,603 cases of injured patients were included, of whom 67,683 were foreign patients. The incidence rate per 100,000 people per year was 2960.5 from locals and 1659.8 from foreigners. Serious outcomes were higher for foreigners than for locals(31.0% versus 23.2%, p<0.001). There was a further difference in the rural region. Length of stay was longer for foreigners(72 versus 69 minutes, median, p<0.001). The transfer rate was also higher for foreigners(1.9% versus 1.6%, p<0.001). Daegu had the highest ratio of foreigners’ injury compared to locals(ratio=0.998). Jeonnam(0.073) was the highest serious outcome rate in Korea, and Jeonbuk(0.070) was the second. The area with the longest length of stay in the Emergency department was the median 139 minutes for locals and 153 minutes for foreigners in Daegu. The more patients per day, the shorter the time spent in the emergency rooms(Spearman correlation coefficient=-0.388). This phenomenon was more prominent in locals(-0.624 versus -0.175). Multivariable logistic regression was used as a dependent variable for the serious outcomes of foreign patients. The foreign patients(OR=1.413, p<0.001), intention, no insurance, age, sex, urban area, low blood pressure, decreased consciousness, transfer, acuity, and length of stay were statistically significant. Conclusion: This study showed that there is a health inequality for foreigners who came to the emergency room due to injury in Korea. Also, serious outcomes from injury in foreigners have been shown to be related to various causes including factors of the foreigner.

Introduction: BACKGOUND In the modern era of terrorism and senseless violence, it is essential that hospital staff have expertise in implementation of a mass casualty incident (MCI) plan. OBJECTIVES 1. To assess current gaps in implementation of an academic urban hospital code orange plan using live simulation and tabletop exercise. 2. To identify and educate front-line staff to champion a hospital-wide MCI plan. INNOVATION Historically, in order to limit resource utilization and impact on patient care, disaster response training of front-line staff involved tabletop exercises only. The tenets of experiential learning suggest that learner engagement through realistic active practice of skills achieves deeper uptake of new knowledge. We enhanced the traditional tabletop approach through novel use of live actor patients presenting to an academic, urban emergency department (ED) during a hospital-wide MCI simulation. Methods: To assess the current code orange plan, an interprofessional, committee comprising expert leaders in trauma, emergency preparedness, emergency medicine and simulation integrated tabletop and live simulation to stage a MCI based on a mock incident at a new subway station. ED staff, the trauma team and champions from medicine, surgery and critical care participated along with support departments such as Patient Flow, Patient Transport, Environmental Services and the Hospital Emergency Operations Centre. Ten live actor patients and eight virtual patients presented to the ED. The exercise occurred in situ in the ED. Other participating departments conducted tabletop exercises and received live actor patients. Results: CURRICULUM Staff decanted the ED and other participating units using their current knowledge of hospital code orange policy. Live and virtual patients were triaged and managed according to severity of injuries. Live actor patients were assessed, intervened and transported to their designated unit. Virtual patients were managed through verbal discussion with the simulation controllers. An ED debrief took place using a plus/delta approach followed by a hospital-wide debrief. Conclusion: CONCLUSION An interprofessional hospital-wide MCI simulation revealed important challenges such as communication, command and control and patient-tracking . The exercise ignited enthusiasm and commitment to longitudinal practice and improvement for identified gaps.