Introduction: Final year emergency medicine residents may be transitioning to practice with little to no training on how to effectively supervise and assess trainees. It remains unclear how comfortable final year residents and new-to-practice physicians are with these competencies. The goal of our study was to examine physician comfort with supervision and assessment, whether there was a perceived need for formal training in these areas, and what gaps, barriers and enablers would exist in implementing it. Methods: Qualitative data were collected in two phases during September 2016-November 2017 through interviews of PGY5 emergency residents and new-to-practice staff at the University of Toronto and McMaster University in Ontario, Canada. A semi-structured interview guide was developed and used during the first round of interviews at the University of Toronto during phase one. Results from phase one were used to refine the interview guide, to be used in phase two, to ensure that all potential areas of thematic generation were touched upon. Phase two occurred at the University of Toronto and McMaster University using the refined interview guide. All transcripts were coded, analyzed, and collapsed into themes. Data analysis was guided by a constructivist grounded theory based in a relativist paradigm. Results: Thematic analysis revealed five themes. Residents and staff alike described acquiring the skills of supervision and assessment passively, primarily through modeling the behaviours of others; the training that is available in these areas is variably used, creating a diversity of physician comfort levels within these two competencies; the many competing priorities in the emergency department represent significant barriers to improving supervision and assessment; providing negative feedback is universally difficult and often avoided, sometimes resulting in struggling trainees not being identified until late in residency; the move towards competency based education (CBE) will act as an impetus for more formal curriculum being required in these areas. Conclusion: As residency programs transition to a CBE model, there will be a greater need for formal training in supervision and assessment to achieve a standard level of comfort and competence among senior residents physicians in independent practice. These competencies will also need an emphasis on how to identify struggling trainees, and how to approach negative and constructive feedback.

Introduction: Prior to opening Strathcona Community Hospital (STCH) site leadership were tasked to develop an innovative care model. The central aim was quality improvement and patient safety optimization in the emergency department (ED) utilizing a nurse practitioner (NP) model. They developed 3 pillars: collaboration, multidisciplinary approach, and integration with the plan of improving patient satisfaction and ensuring no patient gets lost to follow up. NPs work in the STCH ED and the NP led Emergency Department Transition (EDT) Clinic in Ambulatory Care. In the ED NPs provide direct clinical care, judicious review of DI and microbiology reports, and care coordination for patients at risk of lost to follow up. The EDT clinic is an innovative NP lead clinic with the purpose of providing timely, high-quality follow up care for ED patients. Methods: Data for the service delivery indicators came from data repository and manual data collection looking at the following outcomes: timely review of DI/micro results; decreased ED visits for non-urgent/emergent issues; safe transitions in care and improved patient satisfaction. Quantitative data from service delivery, patient and surveys were analyzed using Microsoft Excel and SPSS 19. Results: From June 2016 to January 2017 ED NPs at STCH reviewed 3000 positive microbiology reports and made 517 f/u calls to those patients, and reviewed 3181 DI results. This has freed up approximately 2 hrs per day of ED physician time. When NPs were working in the ED, the number of patients who left without treatment (LWT) was approximately 50% less, and improved STCH ED wait times to be among the lowest in the Edmonton Zone. From June 2016 to January 2017, EDT NPs completed 837 patient visits; 371 letters to family physicians (FPs); 215 referrals; and connected 520 patients to a new FP. Patient satisfaction survey show 88-90% of the patients were satisfied with their care. Conclusion: NPs are integral members of the ED team at STCH, providing direct clinical care and several valuable follow up services for ED patients. The EDT clinic provides urgent follow up for ED patients unable to get a timely appointment with their FP or no access to primary care. The clinic also prevents unnecessary returns to ED, and aids to bridge ED services to family physicians or specialist. NPs are the common thread through all departments at STCH, contributing to quality improvement and high patient satisfaction.

Introduction: Administrative data are attractive for research, policy and quality improvement initiatives as large amounts of data can often be obtained quickly and at low cost. Unfortunately, administrative data often have significant limitations owing to how they were collected and coded. In many cases, free text, often hand written, diagnoses provided by physicians are converted into ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) codes by trained nosologists for administrative purposes. However, because of the large data sets often obtained from administrative sources, it is difficult to verify the accuracy of the data, which may lead researchers to misleading or false conclusions. The objective of this study was to evaluate the accuracy of ICD-10 codes for the diagnosis of pulmonary embolism (PE) in emergency department (ED) patients. Methods: As part of a larger study examining the effectiveness of a clinical decision support intervention on CT utilization and diagnostic yield for ED patients with suspected PE, all patients with an ICD-10 code corresponding to PE (126.0 and 126.9) on ED discharge were obtained from four adult urban EDs and one urgent care center from August 2016 to March 2017. PE diagnosis was confirmed by reviewing electronic medical records and imaging reports for all patients. Discrepancies between coded ICD-10 diagnoses and actual imaging findings were quantified. This study was REB approved. Results: Of 584 ED patients with ICD-10 codes identifying PE as a discharge diagnosis, 535 had imaging that could be reviewed. Of these, 225 (42.1%) did not have clinical diagnoses of PE, and thus were incorrectly coded, resulting in false positive ICD-10 codes. Common coding errors included physician free text diagnoses of rule out PE or query PE being coded as positive for PE. Conclusion: Administrative data are subject to errors in coding. In this study ICD-10 codes were not reliable for the diagnosis of PE, with 42.1% of PE diagnoses being false positives. Similar coding errors are likely for other diagnoses that require waits for confirmatory imaging (e.g. appendicitis). Nosologist coding of physician free text diagnoses is challenging and prone to errors. Consequently, validation of ICD-10 coding prior to analysis of administrative datasets is crucial for meaningful results.

Introduction: It is critical for planning, clinical care and resource optimization to understand patterns of emergency department (ED) utilization. Individuals who have experienced adverse childhood experiences (ACE) are known to have more unhealthy behaviors and worse health outcomes as adults and therefore may be more frequent ED users. Adverse childhood experiences include physical, sexual and emotional abuse or neglect, substance abuse in the family, witnessing violence, having a parent incarcerated or parents getting divorced or separated. To date there are few studies exploring the relationship between ACE and ED utilization. Methods: This a mixed qualitative and quantitative study. It includes analysis of data collected through a survey, a retrospective chart review and focus group discussions. The survey was administered to a convenience sample of adult patients (CTAS 2 -5) presenting to EDs in Kingston Ontario, and consisted of two validated tools that measured exposure to ACE and resiliency. Demographic data and ED utilization frequency for 12 months prior to the index visit were extracted from an electronic medical record for each patient completing the survey. A sample of participants with a high ACE burden (ACE score > 4) were invited to participate in focus groups to explore their experiences of care in the ED. Demographic, ED utilization and health status data were summarized and statistically significant patterns between high ACE and lower ACE patients were determined using Chi2t or t-tests. Transcripts from the focus groups were thematically analyzed using NVivo software by 2 independent researchers. Results: 1693 surveys were collected, 301 (18%) were deemed to have a high ACE score, data analysis is ongoing. The primary outcome is the relationship between ACE and the frequency of ED utilization among adult patients presenting to EDs in Kingston, ON. Secondary outcomes include evaluating the role of resilience as a potential mitigating factor, describing the demographics of high ACE burden frequent ED visitors, and the experiences of care for individuals with high ACE burden in the ED. These outcomes will be utilized to inform hypotheses for future studies and potential interventions aimed at optimizing ED utilization and patient care experience. Conclusion: This study provides novel insight into the relationship between ACE burden and ED utilization while also describing the demographics and experiences of care for ED patients with a high ACE score. Data analysis is on-going.

Introduction: Many patients with advanced or end-stage diseases spend months or years in need of optimal physical, spiritual, psychological, and social care. Despite efforts to provide community care, those with severe illness often present to emergency departments (EDs). This abstract presents preliminary results on the qualitative component of an ED-based mixed methods pilot study. The objective of this qualitative component is to develop and test an interview guide to collect qualitative data on physicians perceptions about unmet palliative care (PC) and end of life care (EOLC) needs in EDs. Methods: A scan of the literature on PC and EOLC in EDs was conducted to develop propositions about what might be expected through the clinician interviews, as well as an interview guide. The interview guide will be piloted with up to four ED physicians. During the interview each physician will describe a case where a PC patient had unmet care needs and the impacts they believe these unmet needs had on patients and families. Interview transcripts will be coded descriptively and then conceptually themed by the researcher who conducted the interview. Interpretations drawn from the interview data, with supporting quotations and comparison to initial propositions, will be presented to members of the research team with experience providing ED care, for further interpretation. Advice of a second trained qualitative researcher will be sought on the richness and relevance of data obtained and how the interview guide could be improved to elicit richer and/or more relevant data. A revised interview guide will be produced alongside rationales for why the proposed revisions will elicit richer data. Results: After reviewing 27 articles on PC and EOLC, propositions and an initial interview guide were developed based on themes from the literature and the study groups experiences. One of the primary results of this pilot work will be an enhanced understanding of PC and EOLC in our local ED context, as reflected in an interview guide revised to elicit richer data than achieved through the initial interview guide. Conclusion: The comparison between our propositions and the study findings will help identify how biases may have influenced interview questions and/or the interpretation of the data. This pilot work to develop an interview guide enhances the rigour of this qualitative work on unmet PC and EOLC needs in EDs.

Introduction: When a female presents with abdominal pain and vaginal bleeding, a positive b-hcg level helps in the diagnosis of an ectopic pregnancy. A timely diagnosis as well as management is required for these cases. In many emergency departments, there can be delays in laboratory processing of quantitative b-hcg levels as well as qualitative urine pregnancy tests. In others, especially in rural hospitals in Canada, the laboratory closes at night and these tests cannot be processed until the morning. This may also help decrease length of stay for some patients in the emergency department. There are currently new point-of-care b-hcg tests on the market using capillary blood, but these are expensive and not readily available. The purpose of the study is to validate the most inexpensive point of care urine pregnancy tests readily available on the market for use with capillary blood samples. These point-of-care tests have only been studied with urine and whole blood. If validated with capillary blood, it would allow for a very practical, rapid, and inexpensive test which could help doctors and nurses to triage patients in a timely and more efficient fashion. Methods: In our emergency department, 385 patients between the ages of 18-50 with possible pregnancy, abdominal pain or vaginal bleeding will be included in the study. A capillary blood sample will be taken and applied to a cassette point-of-care pregnancy test with four drops of saline. Two independent investigators will assess the test. The results will be compared to a quantitative serum hCG assay and urine. If these tests are not done as part of the patients medical care, the patient will be contacted one month after to enquire if the patient is pregnant or not. The sensitivity, specificity, positive and negative predictive values will be calculated. Results: Data colleciton will begin in January 2018. Conclusion: No conclusions can yet be drawn.

Introduction: Incentive spirometry (IS) is commonly used in post-operative patients for respiratory recovery. Literature suggest that it can possibly improve lung function and reduce post-operative pulmonary complication. There is no recommendation about the use of IS in the emergency department (ED). However, rib fractures, a common complaint, increase the risk of pulmonary complications. There is heterogeneous ED practice for the management of rib fractures. The objective of this study is to assess the benefits of IS to reduce potential delayed complications in ED discharged patients with confirmed rib fracture. Methods: This is a prospective observational planned sub-study in 4 canadians ED between November 2006 and May 2012. Non-admitted patients over 16 y.o. with a main complaint of minor thoracic injury and at least one suspected/confirmed rib fracture on radiographs were included. Discharge recommendations of IS use was left to attending physician. IS training was done by ED nurses. Main outcomes were pneumonia, atelectasis and hemothorax within 14 days. Analyses were made with propensity score matching. Results: 450 patients with at least one rib fracture were included. Of these, 182 (40%) received IS with a mean age of 57.0 y.o. Patients with IS seem to have worse condition. 61 (33.5%) had 3 fractures comparatively to 56 (20.9) for patient without IS. Although, the groups were similar for mean age, sex and mechanism of injury. There were in total 76 cases of delayed hemothorax (16.9%), 69 cases of atelectasis (15.3%) and five cases of pneumonia (1.1%). The use of IS was not protector for delayed hemothorax (RR= 0.80, 95% CI [0.45 1.36]) and nor for atelectasis or pneumonia (RR=0.74, 95% CI [0.45 1.36]) Conclusion: Our results suggest that unsupervised and broad incentive spirometry use does not seem to add a protective effect against the development of delayed pulmonary complications after a rib fracture. Further study should be made to assess the usefulness of IS in specific injured population in the ED.

Introduction: Upper gastrointestinal bleeding (UGIB) is a common medical condition presenting to emergency departments (ED) and associated with substantial morbidity, mortality, and healthcare expenditures. Our aim was to evaluate the incidence of patients presenting to ED with UGIB in a large population-based surveillance cohort. Methods: The National Ambulatory Care Reporting System (NACRS) was used to identify all presentations to emergency departments for UGIB in Alberta from fiscal year 2010 to 2015 (n=56519) using the International Classification of Diseases Codes (ICD-10) in any diagnostic position. Baseline characteristics and UGIB incidence were calculated using descriptive statistics. Joinpoint regression models were used to calculate the average annual percent change (AAPC) with 95% confidence intervals (CI). Results: The median age of 56519 UGIB presentations was 56 years (interquartile range: 41 to 74 years), 56% were male, and 245% had at least one comorbidity. At time of disposition from the ED , 48.3% were admitted to or transferred to another hospital, 51.4% discharged, and 0.3% died in the emergency department. Further, 10.8% underwent upper endoscopy during their admission to the emergency department. The annual incidence of UGIB were 230.6 (2010), 232.8 (2011), 241.0 (2012), 242.2 (2013), 244.6 (2014), and 242.2 (2015) per 100,000 person-years. Between 2010 and 2015 the incidence of UGIB presenting to ED significantly increased overtime (AAPC=1.1; 95% CI: 0.3 to 2.0). Conclusion: UGIB is a common presentation to emergency departments and has been increasing overtime. Future studies are necessary to evaluate the underlying cause of UGIB and to determine its burden to Albertas healthcare system.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (<10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (>10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2<90%), hypotension (sBP<90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.

Introduction: The cricothyroid membrane is used as a landmark for emergent surgical airway access. Ultrasound identification of the cricothyroid membrane is more accurate than landmarking by palpation. The objective of this study was to determine whether head of bed elevation affects the position of the cricothyroid membrane as identified by ultrasound. Methods: This was a prospective, observational study on a convenience sample of adult patients presenting to the emergency department. Participants underwent ultrasound scans by trained physicians at 0, 30 and 90 degrees head of bed elevation to identify the cricothyroid membrane. The cricothyroid membrane position identified at 0 degrees was used as a reference, and the change in position of the external landmark of the cricothyroid membrane with the patient at 30 and 90 degrees was measured. Additionally, the patients gender, age, body mass index (BMI) and Mallampati score were recorded for comparison. Linear mixed effects models with 95% confidence intervals were used to determine the effect of head of bed elevation, age, BMI and Mallampati score on the differences between measured distances. Results: One hundred and two patients were enrolled in the study. The average change in position from reference was statistically significant for both 30 degrees [2.72±0.77mm (p<0.01)] and 90 degrees [4.23±0.77mm (p<0.01)] head of bed elevation. The adjusted linear mixed effects model showed age greater than 70, BMI over 30 and higher Mallampati score were associated with greater change in distance between cricothyroid membrane landmarks. Conclusion: There was a statistically significant difference in the position of the cricothyroid membrane comparing 0 degrees to 30 and 90 degrees head of bed elevation. However, the relatively small differences suggest that this finding is not clinically relevant. Further study is required to evaluate if these differences impact the actual successful performance of cricothyrotomy.

Introduction: The purpose of this study is to determine if the introduction of a pre-arrival and pre-departure Trauma Checklist as a cognitive aid, coupled with an educational session, will improve clinical performance in a simulated environment. The Trauma Checklist was developed in response to a quality assurance review of high-acuity trauma activations. It focuses on pre-arrival preparation and a pre-departure review prior to patient transfer to diagnostic imaging or the operating room. We conducted a pilot, randomized control trial assessing the impact of the Trauma Checklist on time to critical interventions on a simulated pediatric patient by multidisciplinary teams. Methods: Emergency department teams composed of 2 physicians, 2 nurses and 2 confederate actors were enrolled in our study. In the intervention arm, participants watched a 10-minute educational video modelling the use of the trauma checklist prior to their simulation scenario and were provided a copy of the checklist. Teams participated in a standardized simulation scenario caring for a severely injured adolescent patient with hemorrhagic shock, respiratory failure and increased intracranial pressure. Our primary outcome of interest was time measurement to initiation of key clinical interventions, including intubation, first blood product administration, massive transfusion protocol activation, initiation of hyperosmolar therapy and others. Secondary outcome measures included a Trauma Task Performance score and checklist completion scores. Results: We enrolled 14 multidisciplinary teams (n=56 participants) into our study. There was a statistically significant decrease in median time to initiation of hyperosmolar therapy by teams in the intervention arm compared to the control arm (581 seconds, [509-680] vs. 884 seconds, [588-1144], p=0.03). Time to initiation of other clinical interventions was not statistically significant. There was a trend to higher Trauma Task Performance scores in the intervention group however this did not reach statistical significant (p=0.09). Pre-arrival and pre-departure checklist scores were higher in the intervention group (9.0 [9.0-10.0] vs. 7.0 [6.0-8.0], p=0.17 and 12.0 [11.5-12.0] vs. 7.5 [6.0-8.5], p=0.01). Conclusion: Teams using the Trauma Checklist did not have decreased time to initiation of key clinical interventions except in initiating hyperosmolar therapy. Teams in the intervention arm had statistically significantly higher pre-arrival and pre-departure scores, with a trend to higher Trauma Task Performance scores. Our study was a pilot and recruitment did not achieve the anticipated sample size, thus underpowered. The impact of this checklist should be studied outside tertiary trauma centres, particularly in trainees and community emergency providers, to assess for benefit and further generalizability.

Introduction: Ultrasonography (US), performed in the Emergency Department (ED) by Emergency Physicians, is well established. Educational studies have shown some promise in training paramedics in US use. We have developed and piloted a novel curriculum for paramedic US education. Methods: Based on an informal needs assessment, an US curriculum for paramedics was developed to include: Basic principles, Focused assessment with sonography for trauma (FAST), cardiac, and vascular access. Participants included ED-based and pre-hospital paramedics including all paramedics with critical care training who routinely perform vascular access and procedural sedation within our ED. Comparisons were made using paired non-parametric tests (GraphPad). Results: Participants (N=9) were provided pre- reading materials prior to completing a 6-hour course, consisting of a mix of didactic and practical sessions with live models and vascular access phantoms. Each module was introduced with a 30 minute didactic session, led by an Emergency Physician trained in US, followed immediately by a 1 hour hands-on session lead by either an Emergency Physician or an Emergency Medicine Resident at a learner to instructor ratio of 3:1. At the end of the course, participants were asked to complete a short 10 minute survey that included (1) an assessment of the course quality with regard to preparatory material and course content/delivery (4 point Likert scale; excellent, good, fair, poor); (2) self reported US knowledge pre and post course on a scale of 1-10 (10 high, 1 low); (3) general yes/no questions related to the future of ECCU paramedical and (4) a subjective written section for additional comments. All participants rated the content favourably: 97% scoring it as excellent, and 3% as good. The participants median self-reported US knowledge score increased from 2/10 (IQR 2-3) to 8/10 (IQR 7.25-8; p=0.009) post- course. All comments from the text field were positive in nature. Conclusion: We report a paramedic US course curriculum, which when piloted resulted in high learner satisfaction and a high rate of self reported improvement in US knowledge. Further study will include an assessment of knowledge acquisition and practical performance. Future modifications in our curriculum will be based on needs assessment and may include additional modules.

Introduction: Patients with chronic diseases are known to benefit from exercise. Such patients often visit the emergency department (ED). There are few studies examining prescribing exercise in the ED. We wished to study if exercise prescription in the ED is feasible and effective. Methods: In this pilot prospective block randomized trial, patients in the control group received routine care, whereas the intervention group received a combined written and verbal prescription for moderate exercise (150 minutes/week). Both groups were followed up by phone at 2 months. The primary outcome was achieving 150 min of exercise per week. Secondary outcomes included change in exercise, and differences in reported median weekly exercise. Comparisons were made by Mann-Whitney and Fishers tests (GraphPad). Results: Follow-up was completed for 22 patients (11 Control; 11 Intervention). Baseline reported median (with IQR) weekly exercise was similar between groups; Control 0(0-0)min; Intervention 0(0-45)min. There was no difference between groups for the primary outcome of 150 min/week at 2 months (Control 3/11; Intervention 4/11, RR 1.33 (95%CI 0.38-4.6;p=1.0). There was a significant increase in median exercise from baseline in both groups, but no difference between the groups (Control 75(10-225)min; Intervention 120(52.5-150)min;NS). 3 control patients actually received exercise prescription as part of routine care. A post-hoc comparison of patients receiving intervention vs. no intervention, revealed an increase in patients meeting the primary target of 150min/week (No intervention 0/8; Intervention 7/14, RR 2.0 (95%CI 1.2-3.4);p=0.023). Conclusion: Recruitment was feasible, however our study was underpowered to quantify an estimated effect size. As a significant proportion of the control group received the intervention (as part of standard care), any potential measurable effect was diluted. The improvement seen in patients receiving intervention and the increase in reported exercise in both groups (possible Hawthorne effect) suggests that exercise prescription for ED patients may be beneficial.

Introduction: Competency-based workplace assessments are important in clinical training. However, feedback and assessment are still often perceived as unsatisfactory, particularly in busy settings such as emergency departments. Currently, little is known about how attending staff physicians sense of self may interface with the processes they use to assess and give feedback to trainees. We aimed to understand how attendings perceive their roles when tasked with conducting assessments and providing feedback to trainees. Methods: We conducted semi-structured, individual interviews with attendings (n=16) who used McMAP (McMaster Modular Assessment Program), a workplace-based assessment system at McMaster Universitys Royal College Emergency Medicine program. Attendings were recruited using snowball sampling. Data were interpreted using thematic analysis, sensitized to the dramaturgical lens and rater cognition frameworks. Results: Attendings identified themselves using three distinct but intimately connected roles when assessing trainee performance: the doctor that ensures the safety and well-being of patients; the coach (educator) that empowers, guides, and supports the next generation of medical doctors; and the assessor that formally assesses a trainees progression through the residency program. These roles are influenced by clinical training and experience, teaching experience and context. Conclusion: The ways in which attendings assess and provide feedback to trainees involve a complex and dynamic process that is influenced by their perceived roles as a doctor, coach, and assessor. Understanding the way attendings view and juggle their roles may provide insight into potentially new approaches to assessment and feedback. Results and implications will be discussed.

Introduction: Clinical context is critical for accurate radiologic interpretation of neuroimaging investigations. The aim of this study was to determine the impact of a change in the Emergency Department (ED) computerized provider order entry (CPOE) interface on the quality of clinical information conveyed in ED neuroimaging requisitions for suspected stroke patients. Methods: Four local EDs utilizing a common CPOE ED Stroke order set were studied before and after the introduction of a mandatory blank free text field requiring clinical information for the radiologist before a computed tomography angiography (CTA) request could be submitted. Prior to this modification, the indication (acute stroke) was pre-filled in the CTA request for convenience with the option of providing additional information at the discretion of the ordering physician. ED physicians were informed of the change as well as the rationale for its implementation. A retrospective pre (90 days) post (30 days) analysis was conducted across four local EDs to evaluate the impact of the CPOE user interface change on the quality of clinical information provided on neuroimaging orders. Patients aged 18 with CTA head and/or neck orders submitted from the order set were included. Patients were excluded if the CTA order was submitted outside of the ED Stroke order set, if order entry was by non-physician personnel, or if the order was modified by the diagnostic imaging department after ED submission. Clinical information from CTA orders were scored as complete, partial, or absent/uninformative based on a standardized rubric of critical elements, including: description of neurological deficit(s), lateralization, and timing of symptom onset or duration. Results were analyzed using chi square analysis. Results: Pre-implementation data from Oct 1, 2015 Jan 1, 2016 (N=652) was compared to post-implementation data from Nov 1 30, 2016 (N=227). The proportion of complete, partial, and absent/uninformative clinical histories were: 45.3%, 31.4%, and 23.3% in the pre-implementation period and 62.6%, 37.4%, and 0% in the post-implementation period respectively. There was a 38.2% relative increase in complete clinical histories, a 19.1% relative increase in partial clinical histories, and a 100% reduction in absent/uninformative clinical histories (p<0.001). Conclusion: The introduction of a mandatory free text field significantly increased the overall quality of clinical information provided on ED neuroimaging orders. This CPOE strategy has the potential to improve diagnostic accuracy and reduce unnecessary delays to imaging interpretation caused by lack of clinical information.

Introduction: At academic hospitals, it is a residents responsibility to teach junior learners. Residents endorse that there is limited education on how to effectively teach junior learners, and suggest a more formal curriculum on how to teach would be beneficial. Emergency Medicine (EM) residencies in North America may have a resident as teacher (RAT) curriculum, however, no Canadian EM study has characterized the impact of a RAT curriculum on residents. Our educational concept was to implement a formalized RAT workshop for residents in an EM residency. We assessed residents attitudes and comfort levels towards teaching in response to the curriculum. Methods: A formal RAT curriculum, provided at a single center in a 6-hour session, was provided for both Royal College and College of Family Physician EM residents. Residents completed a survey evaluating attitudes and behaviours regarding their ability to teach and give feedback as part of their roles as teachers, consistent with Kirkpatricks second level of program evaluation. The surveys were administered pre-workshop, immediately post-workshop, and at 3 and 6 months following the RAT workshop. Results: Residents were surveyed in terms of their attitudes towards teaching on a 5-point likert scale. Our educational concept was delivered through a 6-hour workshop with emphasis on practical teaching skills that residents could incorporate into their practice. Lecture topics included orientation of the learner, giving effective feedback, teaching within a short time frame, as well as an introduction to theory of learning. Lectures were geared to be interactive, and included breakout sessions and group discussions. 21 residents participated in the workshop. Of 18 pre-survey respondents, 89.8% (n=16) had no previous formal training in how to teach, yet 72.21% (n=13) ‘sometimes’ or ‘often’ have a learner on shift with them. There were 15 post survey respondents. 53.33% (n=8) respondents somewhat agreed or agreed they were more likely to teach in response to the workshop, and 56.25% (n=8) responded that they somewhat agreed or agreed they were more comfortable with teaching while in the Emergency Department in an immediate post workshop survey. Conclusion: After a formal RAT curriculum, residents reported that they had increased comfort and were more likely to teach junior learners. Although small and single-centered, our study will help provide a basis for larger RAT studies, evaluating the effect on both residents and junior learners.

Introduction: Hospital admission within 72 hours of emergency discharge is a widely accepted measure of emergency department quality of care. Patients returning for unplanned admission may reveal opportunities for improved emergency or followup care. Calgary emergency physicians, however, are rarely notified of these readmissions. Aggregate site measures provide a high level view of readmissions for managers, but dont allow for timely, individual reflection on practice and learning opportunities. These aggregations may also not correctly account for variation in planned readmissions and other workflow nuances. There was a process in place at one facility to compile and communicate readmission details to each physician, but it was manual, provided limited visit detail, and was done weeks or months following discharge. Methods: A new, realtime 72 hour readmission notification recently implemented within the Calgary Zone provides direct and automated email alerts to all emergency physicians and residents involved in the care of a patient that has been readmitted. This alert is sent within hours of a readmission occurring and contains meaningful visit detail (discharge diagnosis, readmit diagnosis, patient name, etc) to help support practice reflection. An average of 15 alerts per day are generated and have been sent since implementation in April, 2017. Although an old technology, the use of email is a central component of the solution because it allows physicians to receive notifications at home and outside the hospital network where they routinely perform administrative tasks. A secondary notification is sent to personal email accounts (Gmail, Hotmail, etc) to indicate an unplanned admission has occurred, but without visit detail or identifiable information. It also allowed implementation with no new hardware or software cost. Results: A simple thumbs up/down rating system is used to adjust the sensitivity of the alert over time. More than 66% of those providing feedback have indicated the alert is helpful for practice reflection (i.e., thumbs up). And of those that indicated it was not helpful, comments were often entered indicating satisfaction with the alert generally, or suggestions for improvement. For example, consulted admitting physicians are often responsible for discharge decisions and should be added as recipients of the alert. Conclusion: Many physicians have indicated appreciation in knowing about return patients, and that they will reflect on their care, further review the chart, or contact the admitting physician for further discussion. Most are accepting of some ‘expected’ or ‘false positive’ alerts that aren’t helpful for practice reflection. Further tuning and expansion of the alert to specialist and consult services is needed to ensure all physicians involved in a discharge decision are adequately notified.

Introduction: Human factors are a neglected when it comes to crash cart design and function. Using observational assessments and in-house surveys, the process improvement team found that staff use of the crash carts in the University of Alberta ED had significate redundancy, inefficiency and often leading to confusion during use. The process improvement team assessed the layout of the adult crash cart and redesigned the cart format based on observational problems/inefficiencies staff had during resuscitations. It was hoped that staff found the new design more efficient and effective during resuscitations when compared to the old cart. Methods: To effect change, the Rapid result change theory method was utilized to implement the new crash cart prototype. The model was used to evoke excitement and staff participation in front line process improvement. With input from senior staff, the cart was redesigned and placed in resus area where it stood the greatest chance of being used frequently. Once a prototype crash cart had gone live, surveys, based on a 7 point Likert scale compared the old and new cart systems. The resus area housed both old and new carts to facilitate the comparison. The survey assessed 6 domains; visibility of the medications, locating medications, overall organization, time savings, mixing medications and comfort level of using each cart. Results: After the trial, the surveys were collected and analyzed using T-test; the results were significant. There was an overwhelming positive result within all domains when comparing the two carts. There was mean difference ranging from 1.7 to 3.5 comparing when comparing the two carts to each domain. Conclusion: The results were so positive; all seven carts were changed to the same format. The overall impact of the new cart design saved time in both application and turnaround time in restocking.

Introduction: There is a significant gap between the number of organ donors and people awaiting an organ transplant; therefore it is essential that all potential donors are identified. Given the nature of Emergency Medicine it is a potential source of organ donors. The purpose of this study is to determine what percent of successful donors come from the Emergency Department (ED) and whether there are any missed potential donors. Methods: Electronic searches of EMBASE, MEDLINE, and CINAHL were performed July 7, 2017 using PRISMA guidelines. Primary literature in human adults were included if they described identification of patients in the ED who went on to become successful solid organ donors, or described missed potential donors in the ED. Data on the total population of actual or missed donors was required to allow calculation of a percentage. Studies describing non-solid organ donation, consent, ethics, survey of attitudes, teaching curricula, procurement techniques, donation outside the ED, and recipient factors were excluded. 2 authors independently screened articles for inclusion and discrepancies were resolved through consensus. Quality was assessed using STROBE for observational studies. Heterogeneity of patient populations precluded pooling of the data to conduct a meta-analysis. Results: 1058 articles were identified, 17 duplicates were removed, 800 articles were excluded based on title and abstract, and 217 full text articles were excluded, yielding 24 articles for the systematic review. For neurologic determination of death (NDD), ED patients comprised 4 44% of successful donors. ED death reviews revealed 0 84% of patients dying in the ED are missed as potential donors and hospital-wide death reviews revealed 13 80.9% of missed donors die in the ED. For donation after cardiac death (DCD), 4 20% of successful donors came from the ED and studies investigating potential donors suggest 2 36% of patients dying the in the ED could be potential DCD donors. The most common population of successful DCD organ donors was in traumatic cardiopulmonary arrest (TCPA), with 3.6 8.9% of TCPA patients presenting to the ED becoming successful donors. Conclusion: Patients dying in the Emergency Department are a significant source of both successful organ donors and missed potential donors. Emergency physicians should be familiar with their local organ donation protocol to ensure potential organ donors are not missed.