Introduction: Extracorporeal Life Support in the context of cardiac arrest (ECPR) is an emerging resuscitative therapy which has shown promising results for patients who may not otherwise survive. As a resource-intensive intervention, ECPR requires carefully selected patients to maximize its potential benefits and mitigate undue harm. This retrospective health records review sought to identify the characteristics of cardiac arrest patients presenting to two academic tertiary care Emergency Departments (EDs) in order to assess the feasibility and impact of an ECPR program. Methods: We reviewed charts for all patients aged 18-75 years old presenting to two Academic Teaching Hospitals with out-of-hospital or in-ED refractory cardiac arrest from January 2015 to December 2016. Based on a review of existing ECPR literature, we defined two sets of liberal and restrictive criteria associated with survival and applied these to our cohort for possible initiation of ECPR. The chart review was completed by one of the principal investigators, with 10% of charts randomly reviewed by a second investigator to ensure good inter-agreement. Any discrepancies or ambiguities found in the review were resolved collaboratively between both investigators. Results: A total of 220 charts were identified and 191 deemed eligible for inclusion in the study. The median age was 59 (IQR: 49.5-67) years and the cohort was 72% male. The initial presenting rhythm was identified as VT/VF in 47% of patients. 65% of arrests were witnessed, with immediate bystander CPR performed on 50% patients and an additional 12% receiving CPR within 10 minutes of collapse. 60% of patients had cardiac arrest lasting less than 75 minutes. 69% of patients were identified as having a reversible cause of cardiac arrest. A favorable premorbid status was identified in 76% of patients. Application of our two sets of ECPR inclusion criteria revealed that 17% and 3% of patients for the liberal and restrictive criteria respectively, would have been candidates for ECPR. Conclusion: At our centre, we identified that in a two-year period, 3% to 17% of cardiac arrest patients presenting to the ED would have met inclusion criteria for ECPR, translating to an additional 0.2-1.4 patients per month admitted for critical care. These findings would suggest that the implementation of an ECPR program at our institution has the potential to have a positive impact for patients with only a relatively low volume of patients requiring additional resources.

Introduction: Emergency Departments (EDs) are frequently the first point of entry to access health services for First Nation (FN) members. In Alberta, FN members visit EDs at almost double the rate of non-FN persons. Furthermore, preliminary evidence demonstrates differences in ED experience for FN members as compared to the general population. The Alberta First Nations Information Governance Centre, Maskwacis Health Services, Yellowhead Tribal Council, Treaty 8 First Nations of Alberta, and Alberta Health Services are working together to research FN members ED experiences and concerns. Methods: This is participatory research guided by a two-eyed seeing approach that acknowledges the equal value of both Western and Indigenous worldviews. FN and non-FN leaders researchers are full partners in the development of the research project. Six sharing circles will be held in February 2018 across Alberta, with Elders, FN patients, FN and non-FN clinicians and FN and non-FN administrators. Sharing circles are similar to focus groups, but emphasize everyone having a turn to speak and demonstrating respect among participants in accordance with FN protocols. Elders will select the questions for discussion based on topics that arose in initial team meetings. Sharing circle discussions will be audio recorded and transcribed. Analysts will include both Western and Indigenous worldview researchers, who will collaboratively interpret findings. Elders will review, discuss, contextualize and expand upon study findings. The research is also guided by FN principles of Ownership, Control, Access, and Possession of FN information. It is through these principles that First Nation research projects can truly be classified as FN lead and driven. Results: Based on initial team meeting discussions, results of sharing circles are expected to provide insights on issues such as: healing, patient-provider communication (verbal and non-verbal), shared decision making, respect for patient preferences, experiences leading to trust or distrust, understandings of wait times and triage, times when multiple (repeat) ED presentations occur, distances travelled for care, choosing specific EDs when seeking care, impacts of stereotypes about FN patients, and racism and reconciliation. Conclusion: Understanding FN ED experience and bringing FN perspectives to Western conceptions of the goals and provision of ED care are important steps toward reconciliation.

Introduction: ex-specific diagnostic cutoffs may improve the test characteristics of high-sensitivity troponin assays for the diagnosis of myocardial infarction. Sex-specific cutoffs for ruling in MI improve the sensitivity of the assay for MI among women, and improve the specificity of diagnosis among men. We hypothesized that the use of sex-specific high-sensitivity Troponin T (hsTnT) cutoffs for ruling out MI at the time of ED arrival would improve the classification efficiency of the assay by enabling more patients to have MI ruled out at the time of ED arrival while maintaining diagnostic sensitivity. The objective of this study was to quantify the test characteristics of sex-specific cutoffs of an hsTnT assay for acute myocardial infarction (AMI) when performed at ED arrival in patients with chest pain. Methods: This retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs were, excluding those with ST-elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes was AMI at 7 days. Secondary outcomes included major adverse cardiac events (MACE: all-cause mortality, AMI and revascularization) and the individual MACE components. We quantified test characteristics (sensitivity, negative predictive value, likelihood ratios and proportion of patients ruled out) for multiple combinations of sex-specific rule-out cutoffs. We calculated net reclassification improvement compared to universal rule-out cutoffs of 5ng/L (the assays limit of detection) and 6ng/L (the FDA-approved limit of quantitation for US laboratories). Results: 7130 patients, including 3931 men and 3199 women, were included. The 7-day incidence of AMI was 7.38% among men and 3.78% among women. Universal cutoffs of 5 and 6 ng/L ruled out AMI with 99.7% sensitivity in 33.6 and 42.2% of patients. The best-performing combination of sex-specific cutoffs (8g/L for men and 6ng/L for men) ruled out AMI with 98.7% sensitivity in 51.9% of patients. Conclusion: Sex-specific hsTnT cutoffs for ruling out AMI at ED arrival may achieve substantial improvement in classification performance, enabling more patients to be ruled out at ED arrival, while maintaining acceptable diagnostic sensitivity for AMI. Universal and sex-specific rule-out cutoffs differ by only small changes in hsTnT concentration. Therefore, these findings should be confirmed in other datasets.

Introduction: High fidelity in-situ simulation has been found to detect system deficiencies, equipment failures, and conditions predisposing to medical errors, also known as latent safety threats (LST). What is not well reported is whether these LSTs are effectively managed. As a part of an ongoing quality improvement project, multidisciplinary, in-situ simulations were conducted across emergency departments (ED) in the Edmonton zone with the aim to identify LST and subsequently manage them to improve patient care. Methods: In 2017 simulations were conducted at EDs in the Edmonton Zone (N=10). Following each simulation, a cross sectional, survey based assessment tool, was completed by participants to identify LST. These LST were shared with the site clinical nurse educator and/or site manager and a management plan made. Two to six months follow-up was made to track progress. For reporting, LST were grouped into themes, progress on LST were coded as either resolved, ongoing, or not managed. Results: A total of 112 LST were identified through 18 separate simulations. The most commonly identified LTS were: resuscitation resource required (n 23), lack of staff training (21), equipment not immediately available (20), IT resource required (8), medication not immediately available (6), staff requiring familiarization (5), medication resource required (5), IT issue (4), large equipment needed (4), small equipment needed (4), lack of staff resource (3), medication needed, (3), equipment malfunction (2), Environment cluttered (2), non-appropriate resource removed (2). Site follow-up identified a total of 52 LST that where resolved, and 60 LST that had ongoing work to manage them. No occurrences of LST not being managed were identified. Conclusion: Simulation was used to effectively identify LST. Creating a structured plan and follow up allowed many LST to be resolved and effectively managed. In 2018 simulation will reassess if LST remain.

Introduction: The ECG diagnosis of acute coronary occlusion (ACO) in the setting of ventricular paced rhythm (VPR) is purported to be impossible. However, VPR has a similar ECG morphology to LBBB. The validated Smith-modified Sgarbossa criteria (MSC) have high sensitivity (Sens) and specificity (Spec) for ACO in LBBB. MSC consist of 1 of the following in 1 lead: concordant ST Elevation (STE) 1 mm, concordant ST depression 1 mm in V1-V3, or ST/S ratio <−0.25 (in leads with 1 mm STE). We hypothesized that the MSC will have higher Sens for diagnosis of ACO in VPR when compared to the original Sgarbossa criteria. We report preliminary findings of the Paced Electrocardiogram Requiring Fast Emergency Coronary Therapy (PERFECT) study Methods: The PERFECT study is a retrospective, multicenter, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms suggestive of acute coronary syndrome (e.g. chest pain or shortness of breath). Data from four sites are presented. Acute myocardial infarction (AMI) was defined by the Third Universal Definition of AMI. A blinded cardiologist adjudicated ACO, defined as thrombolysis in myocardial infarction score 0 or 1 on coronary angiography; a pre-defined subgroup of ACO patients with peak cardiac troponin (cTn) >100 times the 99% upper reference limit (URL) of the cTn assay was also analyzed. Another blinded physician measured all ECGs. Statistics were by Mann Whitney U, Chi-square, and McNemars test. Results: The ACO and No-AMI groups consisted of 15 and 79 encounters, respectively. For the ACO and No-AMI groups, median age was 78 [IQR 72-82] vs. 70 [61-75] and 13 (86%) vs. 48 (61%) patients were male. The median peak cTn ratio (cTn/URL) was 260 [33-663] and 0.5 [0-1.3] for ACO vs. no-AMI. The Sens and Spec for the MSC and the original Sgarbossa criteria were 67% (95%CI 39-87) vs. 46% (22-72; p=0.25) and 99% (92-100) vs. 99% (92-100; p=0.5). In pre-defined subgroup analysis of ACO patients with peak cTn >100 times the URL (n=10), the Sens was 90% (54-100) for the MSC vs. 60% (27- 86) for original Sgarbossa criteria (p=0.25). Conclusion: ACO in VPR is an uncommon condition. The MSC showed good Sens for diagnosis of ACO in the presence of VPR, especially among patients with high peak cTn, and Spec was excellent. These methods and results are consistent with studies that have used the MSC to diagnose ACO in LBBB.

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. The pulmonary embolism rule-out criteria (PERC) can identify patients who can be safely discharged from the ED without further investigation for PE. The purpose of this study is to evaluate the use of the PERC rule in the ED and to compare the rates of testing for PE if the PERC rule was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the negative predictive value was calculated. Results: There were 1,163 patients that were tested for PE and 1,097 patients were eligible for our analysis. Of the total, 330/1,097 (30.1%; 95%CI 27.4-32.3%) had CT/VQ imaging for PE, and 48/1,097 (4.4%; 95%CI 3.3-5.8%) patients were diagnosed with PE. 806/1,097 (73.5%; 95%CI 70.8-76.0%) were PERC positive, and of these, 44 patients had a PE (5.5%; 95%CI 4.1-7.3%). Conversely, 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients were PERC negative, and of these, 4 patients had a PE (1.4%; 95%CI 0.5-3.5%). Of the PERC negative patients, 291/291 (100.0%; 95%CI 98.7-100.0%) had a D-dimer test done, and 33/291 (11.3%; 95%CI 8.2-15.5%) had a CT angiogram. If PERC was used, CT/VQ imaging would have been avoided in 33/1,097 (3%; 95%CI 2.2-4.2%) patients and the D-dimer would have been avoided in 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients. Conclusion: If the PERC rule was used in all patients with suspected PE, fewer patients would have further testing. The false negative rate for the PERC rule was low.

Introduction: A two-year Stroke Ambulance (SA) pilot project was implemented at the University of Alberta Hospital (UAH) in February, 2017, the first in the world to utilize this specialized technology in a rural setting. The primary objective is to evaluate clinical and economic implications of timely SA assessment and treatment of hyperacute stroke patients who present to non-stroke centres in rural Alberta and might otherwise have received delayed treatment, or not at all, due to prolonged transfer times. Methods: A steering committee and seven working groups were established, with representation from Alberta Health Services (AHS) programs impacted, to ensure comprehensive project development and implementation. The SA portable CT scanner, point of care laboratory, and videoconference system facilitate diagnosis of stroke in the field. The multidisciplinary team includes a stroke fellow, advanced & primary care paramedics, registered nurse, CT technologist, and telestroke physician. When not dispatched, the team provides stroke expertise and patient care in the emergency department (ED) and diagnostic imaging. The service model includes suspected stroke patients presenting to non-stroke centres within a 250 Km radius of Edmonton (Phase I); patients presenting to Edmonton Zone (EZ) hospitals without CT capability and/or tPA protocols (Phase 2); and expedited transport from EZ hospitals to the UAH for urgent endovascular therapy (EVT) (Phase 3). A health economic analysis will compare stroke ambulance care with standard care. Results: The SA has responded to 54 dispatches, 13 patients thrombolyzed and 3 patients receiving EVT. Median rendezvous to CT time was 10 minutes, median rendezvous to tPA time was 21 minutes, and mean time from symptom onset to tPA was 180 minutes. There were no complications. After SA imaging and assessment, 18 patients were repatriated back to their local community hospital, avoiding unnecessary admission to tertiary care. Conclusion: Our preliminary experience demonstrates that the SA offers a novel approach to performing timely evaluation and treatment of suspected stroke from non-stroke centres and may serve as an excellent triage mechanism, reducing avoidable admissions to overcapacity tertiary care EDs. The SA team provides added value to the ED with stroke expertise and patient care. A comprehensive health economic analysis will determine cost-effectiveness and whether spread is feasible.

Introduction: Current treatment guidelines advocate for the aggressive management of both high-risk and subsets of moderate-risk pulmonary embolism (PE) with fibrinolytic therapy. However, there is limited evidence on the risks and benefits of fibrinolytic therapy in PE, with mortality improvement still to be proven. This study aimed to report the incidence of major bleeding and death after thrombolysis for PE. Methods: A health records review was performed on data from two hospitals between 2007 and 2017. Pharmacy identified all patients who had received either alteplase or tenecteplase. Trained abstractors reviewed each chart to determine the indication for thrombolytic therapy. Patients were included if they received systemic thrombolysis for diagnosed or presumed PE. Data was extracted on 30-day mortality, International Society of Thrombosis and Hemostasis defined major bleeding within 30 days, premorbid anticoagulant and antiplatelet prescription, age, sex, comorbidities, renal function, history of bleeding, type and dose of thrombolytic and category of PE (high or moderate risk). Results: 1534 patients were identified, of which 72 received systemic thrombolysis for PE. The median age was 57, 34 were male, 17 with a history of venous thrombosis and 12 with cancer. Fifty-four were classified as having high-risk PE, of whom 39 received cardiopulmonary resuscitation (CPR) when thrombolysis was administered. Formal confirmatory imagining for PE was obtained in only 23/39 patients who were in cardiac arrest. Eighteen patients were classified as moderate-risk PE. The incidence of major bleeding was 28/54 (52%, 95% CI 39-65%), and 3/18 (17%, 95% CI 6-39%) for the high and moderate risk groups respectively. There were 4 intracranial bleeds, all in the high-risk PE group. The only significant predictor of major bleeding was the need for CPR at the point of administration of the thrombolytic agent (OR 2.6, 95% CI 1.0-7.5, adjusted for age). Thirty-four patients died within 30 days (47%, 95% CI 36-59%), all in the high-risk PE group. Death was not associated with any demographic variable on univariate analysis. Death occurred in 28/39 (72%, 95%CI 56-83%) patients who received CPR and 6/33 (18%, 95% CI 9-34%) who did not. Conclusion: We found a high incidence of 30-day major bleeding and death following administration of thrombolysis for PE which will help inform future prognostic discussions in our institution.

Introduction: High quality Cardiopulmonary Resuscitation (CPR) saves lives, however skill retention after standard Basic Life support (BLS) courses has been shown to be poor. Our goal was to develop a student-run, mentorship based program to allow repetitive practice of BLS skills while minimizing resource commitment and time requirements. Methods: We developed a top down training program that relied on online teaching resources, regular simulation training and near-peer feedback. First year medical students were given the opportunity to participate in the program and baseline CPR quality was documented. They were then divided into intervention and control groups. The intervention group participated in bi-monthly 40-minute small group training sessions directed by senior medical students and monitored by a staff physician. The control group received no further training. At the end of the 8-month study period CPR quality was documented for all participants. Results: We included data from 54 medical students. Overall compression depth and rate were monitored using Laderall SimMan 3G(TM) high-fidelity CPR mannequins. Average rate and depth of compression were significantly improved in the intervention group relative to both the control group that did not receive training, as well as relative to the intervention groups own pre intervention values (both with p values below 0.05 using Mann-Whitney tests and an intention to treat analysis for loss to follow up). Conclusion: Our study demonstrated a significant improvement in CPR quality as a result of our intervention. Survey data also indicated positive feedback from participants in relation to comfort with in-hospital CPR. As such we intend to continue to run this program, identifying participants each year whom can move into training and leadership roles to help foster CPR and basic resuscitation in our medical community.

Introduction: Cannabis hyperemesis syndrome (CHS) is associated with long-term, regular use of marijuana. CHS patients typically present to emergency departments (ED) during a hyper-emetic phase of paroxysmal nausea and vomiting. Despite extensive investigations as well as frequent ED presentations, CHS patients have a delayed time to diagnosis, and many are often missed. To date, there is a paucity of research examining CHS in emergency departments. Our objective was to identify CHS cases presenting to EDs within the Calgary health region, and to quantify the number of patients and frequency of ED visits for CHS. Methods: A retrospective chart review was performed on all patients who presented to any Calgary ED or urgent care center between January 1, 2015 and December 31, 2016 (ages 18 55 years) who had an ED discharge diagnosis of either nausea or vomiting alone, nausea with vomiting, or poisoning by cannabis, as identified in administrative data. Data abstraction from medical records was performed by trained personnel using standardized forms with comprehensive inclusion criteria for CHS. Results: The search strategy yielded a total of 320 ED visits from 156 individual patients. 55% of visits were by males, and 45% by females. The average age was 29.5 years. Of the 156 patients, 53% had cannabis use documented in the chart, with 51% reporting daily and/or regular cannabis use. Relief of symptoms from use of hot showers (a pathognomonic finding) was found in 17% of patients. 18% of patients (n=28) met criteria for CHS, and 28% (n=44) met partial criteria for CHS (having documented regular cannabis use, cyclic vomiting and abdominal pain) but no record of symptom resolution with cessation of cannabis use or from the use of hot showers. Patients meeting CHS criteria had an average of five repeat ED visits during the study period with 16% (n=12) of ED visits resulting in hospital admission. Conclusion: We identified a large cohort of patients with confirmed or suspected CHS. Given that nearly one third of the sample met partial criteria for CHS highlights the need for improved patient screening, as it is possible that this cohort may include missed cases. Further, many CHS patients are not responsive to first-line anti-emetics and accurate diagnosis is crucial for managing these patients effectively in the ED. This is of particular importance given the admission rate for CHS and resulting burden on the health system.

Introduction: Tertiary care emergency departments (EDs) in large urban environments may have a low volume of high acuity pediatric presentations due to their proximity to dedicated childrens hospitals or large community centres. This may lead to discomfort among emergency physicians (EPs) and registered nurses (RNs) in managing these patients and a waning of knowledge and skills for this unique population. Among the EP group at our institution, 68% indicated they managed pediatric patients in less than 25% of their shifts, 68% also indicated they were uncomfortable managing an undifferentiated critically unwell neonate and only 32% indicated they would be comfortable teaching pediatric topics to emergency medicine residents. At our institution, our innovation was to create a useful curriculum for certified EPs and RNs to improve the interdisciplinary teams comfort level, knowledge and skill set when managing pediatric emergencies. Methods: A needs assessment was undertaken of the EPs and RNs working in our centre. This information was used to develop intended learning outcomes in a collaborative manner with the clinical nursing educator and physician curriculum leads. The team further collaborated with the local simulation centre and a pediatric emergency physician from the local childrens hospital. Results: A one-year, three-module curriculum was developed to cover the areas felt to be highest yield by the EP group: febrile illness, respiratory disease and critically ill neonates and infants. Each module contains three components: an in person interactive lecture delivered by an EP who routinely manages pediatric patients, either at a childrens hospital or large community centre; an online component with e-mail blasts of high yield pediatric content; and, culminating in an interdisciplinary interdepartmental simulation held in situ. This latter is particularly important so that all members of the interdisciplinary team can practice finding and using equipment based on its actual location within the ED. Each component of each module is then evaluated by the participants to ensure improvement for subsequent delivery. Conclusion: Well delivered continuing professional development (CPD) will become increasingly important as competence by design becomes the model for maintenance of certification. Maintaining skills for pediatric patients is an important component of CPD for physicians working in general emergency departments that see a low volume of high acuity pediatric presentations. Our curriculum seeks to address this identified need in an innovative manner using a modular and interdisciplinary approach with a diversity of teaching methods to appeal to the learning styles among our health care team.

Introduction: Atrial fibrillation and flutter (AFF) represent the most common arrhythmia presentations to emergency departments (EDs). Some research suggests that women with AFF experience different symptoms, receive different treatment and have worse outcomes than men. This study explored sex differences in risk factors, medication, and outcomes before and after ED visits for acute AFF. Methods: Adult patients presenting to the one of three hospitals affiliated with the University of Alberta with acute AFF were enrolled. Following informed consent, each patient completed a survey administered by a trained researcher, administrative ED information (e.g., ED times) was collected from the ED information system, a chart review on treatments was conducted and patients were contacted for follow-up at 7 days via telephone. Descriptive (median and interquartile range {IQR} and proportions) and simple (Wilcoxon-Mann-Whitney, chi-square, z-proportion) statistics are presented for continuous and dichotomous outcomes. Results: Overall, 217 patients were enrolled; the median age was 64 years (IQR: 55, 73) and 39% were female. Males presenting to the ED with AFF were 10 years younger than females (p<0.001); however, females weighed significantly less (median weight 69 vs. 95 kg; p<0.001), consumed less alcohol (12 vs 60 drinks/year; p<0.001) and were less likely to be ex-smokers (p=0.022) than men with AFF. Women arrived by Emergency Medical Services (EMS) (p=0.037), experienced palpitations (p=0.042), and reported a history of hypertension (p=0.022) more frequently than men. Females were more often prescribed oral anticoagulants before (p= 0.041) and after (p=0.011) the ED visit, and females with a history of AFF were less likely to present without anticoagulant/antiplatelet therapy (p=0.015). Overall, both sexes had similar attempts at cardioversion (59.4% vs. 61.3%) and hospitalizations (12.5% vs. 8.6%), respectively. If initial chemical cardioversion failed, females were more likely to receive subsequent electrical cardioversion (60.0% vs. 26.7%, p=0.036) than men. Conclusion: Overall, both women and men present frequently to the ED with AFF. Compared to men with AFF, women present with symptoms 10 years later, have different risk factors, experience more severe symptoms and use EMS more commonly; however, outcomes were similar. Unexplained sex-based variations in-ED and post-ED management are evident and these differences warrant further scrutiny.

Introduction: Emergency medicine (EM) is known to be a high-stress specialty. Work related stress and burnout have been reported to negatively impact physician-patient interactions, collaboration and ultimately overall physician mental and physical health. We sought to assess the rates of burnout among emergency physicians working at a single large Canadian tertiary care center and to identify higher risk groups. We hypothesized burnout rates to be uniformly high. Methods: We conducted a local cross-sectional study to assess burnout among adult and pediatric emergency physicians, fellows and residents at London Health Sciences Centre (LHSC). A total of 118 participants were invited to complete an anonymous online survey encompassing demographics, the validated MBI tool (Maslach Burnout Inventory) with additional questions aimed at identifying determinants of emergency physician burnout at LHSC. Each respondents three MBI scale scores for Emotional Exhaustion, Depersonalization and Personal Accomplishment were recorded with a possible range of 0-6. Descriptive statistics were calculated and relationships between risk factors (age, gender, years of practice, marital status, and credentials) and burnout scores were examined using t-tests, one-way ANOVAs, and/or regression analyses where appropriate. Results: To date the survey had a 50% (59/118) response rate. Of the 59 respondents 24 (40%) were female, the mean (SD) age was 40.6 years (10.5) and years of practice ranged from 1 to 35, with a mean of 13. Survey results indicated a high degree of burnout among LHSC EM physicians with a mean (SD) Emotional Exhaustion Score of 2.9 (1.3) and Depersonalization score of 2.4 (1.3), indicating that physicians felt burnt out from work between once a day to once a week. Inversely, the protective variable of Personal Accomplishment, with a score of 4.7 (0.9), indicated daily to weekly feelings of accomplishment. Female physicians (independent samples t-test, p=0.003) and those having fewer years of practice (linear regression, R2=0.188, p=0.04) were identified to have higher burnout. We did not identify any factors associated with Personal Accomplishment. Conclusion: Consistent with previous literature, LHSC emergency physicians were shown to be at risk for moderate to severe burnout. High risk groups identified included gender (female) and fewer years of practice. We did not identify any factors to be protective. Despite this, LHSC emergency physicians showed a high degree of personal accomplishment. While all physicians experience burnout, targeted interventions to newer female staff could have the highest benefit.

Introduction: Hospital access block, often called Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving Health Care system. The multiple, dynamic, and inter-dependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems analysis and approach. One technique described in similar contexts is Front Line Ownership (FLO) based on the theoretical framework of positive deviance. The aim of this study is to discover where pragmatic bottom-up insights and adaptive work-arounds can be elicited, described, iterated, and potentially implemented at a broader scale to catalyze systems change, in service of improving patient flow. Methods: This is a qualitative study which identified, convened, and surveyed stakeholders representing three components of the system. Purposive sampling was used to gather a full range of perspectives from three groups: 1) patients and or families, 2) front-line providers, and 3) management/leaders. Interviews were recorded and transcribed by a third party, then each transcription was coded independently by two investigators (at least one of which was the PI). Informed consent was obtained from all participants and each was offered the opportunity to review the transcription to ensure accuracy. A framework analysis was used to synthesize, reflect upon, and interpret the data from multiple perspectives using a structured, iterative approach. Results: In part 1 of this study, three broad over-lapping themes emerged from the analysis as being areas of opportunity for reducing hospital access block. They are: 1. Boundary Conditions (the historical, organizational cultural, psychological, economic, and other contexts influencing system performance), 2. Systems Integration (how well the parts interface with each other relate to the whole), and 3. Operations management (the more technical aspects of patient flow). When these three broad themes are cross-analyzed with a more conventional input-throughput-output approach, previously under-emphasized avenues for improvement may become apparent. Conclusion: A front-line ownership analysis of ED overcrowding is feasible. There are adaptive behaviors by some front-line individuals at each “level” of perspective that have been identified and could be modified and implemented locally to improve patient flow in the ED (and the rest of the health system).

Introduction: Tourniquets are a mainstay of hemorrhage management. However, there is insufficient evidence to guide device sselection. This review analyses the literature on tourniquets, for the following outcomes: lower-extremity arterial hemostasis, application speed, and pain. Methods: Studies were limited to English. Non-human studies, case series, and intra-operative applications were excluded. A systematic review of MEDLINE, PubMed, Google Scholar, and the Cochrane Database from 1992 to Dec 2017 was performed. Article citations were also assessed. Results: Twenty-one studies met criteria, testing 28 tourniquet devices. The most popular devices for arterial hemostasis were the Combat Application Tourniquet (C-A-T) (662 applications), Special Operations Forces Tactical Tourniquet (SOFTT) (307 applications), blood pressure cuff (80 applications), rubber tubing (58 applications) and the Emergency Medical Tourniquet (EMT) (52 applications). The blood pressure cuff achieved the highest (weighted averages) rate of 99% (95% CI 93 to 100) based on four studies of 80 applications. Followed by the EMT which achieved 83% (95% CI 72 to 93), based on three studies of 52 applications (p<0.01). The fastest device to apply, taking 17 seconds (95% CI 11 to 23), was surgical tubing, based on two studies totalling 30 applications. The next fastest was the blood pressure cuff, requiring 20 seconds (95% CI 18 to 22), based on two studies totaling 58 applications (though there was no statistical difference in application time, p=0.08). Tolerance could not be analyzed, due to heterogeneity of outcome measures. Conclusion: This is the first meta-analysis of tourniquet outcomes. The literature lacks a standard approach to device application. The quality of evidence is of very low due to the small sample sizes, lack of blinding, selective outcome reporting and result inconsistency. Common medical equipment appear to outperform commercial tourniquets for arterial hemostasis and speed of application; however, they are some of the least studied devices.

Introduction: Prehospital blood transfusion has been adopted by many civilian helicopter emergency medical service (HEMS) agencies and early outcomes are positive. Shock Trauma Air Rescue Service (STARS) operates six bases in Western Canada and in 2013 implemented a prehospital transfusion program. We describe the processes and standard work ensuring safe storage, administration, and stewardship of this precious resource. Our aim was to produce a sustainable and safe blood storage system that could be carried on each mission flown. Methods: Close collaboration with transfusion services and adherence to Canadian Transfusion Standards was key at each step of development. An inexpensive, reusable, temperature controlled thermal packaging device was obtained along with an electronic temperature logger. Conditioning of the device and temperature maintenance (1 6C) was tested to ensure safe storage conditions. Online training programs were developed for air medical crew (AMC) as well as transport physicians (TPs) regarding administration indications, safety, and stewardship processes. Blood traceability and usage was monitored on an ongoing basis for quality assurance. Results: Two units of O negative packed red blood cells (pRBCs) are now carried on each flight. The blood box is conditioned and prepared by transfusion services for routine exchange every 72 hours. If pRBCs are administered the blood bank is immediately notified for preparation of another cooler. Unused blood is returned to blood bank circulation. Conclusion: The introduction of the STARS blood on board program supports the provision of emergent transfusion to selected patients in the pre-hospital environment. Our standard work and stewardship processes minimize wastage of blood products while keeping it readily available for critically ill and injured patients. Subsequent work will aim to describe characteristics and patient centred outcomes.

Introduction: Seeking patient outcome feedback (POF), defined as obtaining information on a patients clinical course beyond ones care, is crucial to the learning process. However, the lack of POF is a major pitfall of emergency medicine. Emergency department (ED) bouncebacks, which are characterized as patients with unplanned returns to the ED after being discharged, are an important type of POF to study because they represent a potential misdiagnosis or mismanagement and can highlight areas for physician self-improvement. Currently, most hospitals do not relay details about ED bouncebacks back to the treating physician, unless a grave error occurred. This studys purpose is to provide weekly reports to all physicians in the ED on patients who have unplanned returns within 7 days of discharge from the ED, and evaluate the impact this has on the physicians practice on seeking POF. Methods: A new weekly report was distributed to physicians working at an academic hospital outlining the patients who have returned within 7 days of discharge from the ED, their new presenting complaint and final disposition. An online survey was also administered to all ED staff evaluating the amount of POF they sought pre and post report, and their attitude towards the new reports. Results: 22 responses were received, for a response rate of 85%. The majority of respondents follow the reports (73%) and actively seek POF by looking up patients charts and results(70%). Additionally, 58% state that they seek POF more often since receiving these reports, for both the bouncebacks and their other patients. Furthermore, 37% claimed that the reports helped improve the appropriateness of their referrals and 32% stated it helped increase their confidence in their clinical practice. The majority of physicians (87%) found the reports to be helpful and would like to continue receiving it. Conclusion: Weekly bounceback reports are a high-yield tool for increasing POF sought in the ED and have benefits for both the physician and the department as a whole. They can be used to not only identify patients who may have had an error in their management, but also help to improve physicians’ clinical skills by encouraging and enabling follow-up of patients they managed. Thus, bounceback reports are a valuable tool to provide to physicians and should be considered by ED Departments.

Introduction: Aeromedical helicopters and fixed wing aircraft are used across Canada to transfer patients to definitive care. Given height limitation in aeromedical transport, CPR performance can be affected. An adapted manual compression technique has been proposed by H. Koch (pron. Cook) that uses the elbow to compress the sternum rather than the conventional hand. This preliminary study evaluated the quality of Koch compressions versus conventional bimanual compressions. Methods: Paramedics (5), registered nurses (3) and a physician (1) were recruited. Each participant performed a 2 minute cycle of each technique, were randomized to determine which technique was performed first, and rested 5 minutes between compression cycles. A Resusci Anne SkillReporter manikin atop a stretcher in a BK117 helicopter was used. The compressors performed without feedback or prompting. Outcomes include compression rate, depth, recoil, and fatigue. Results: The mean conventional compression rate was (bpm) 118 +/− 13 versus 111 +/− 10 in the Koch scenario (p=0.02) (target 100 to 120). Mean conventional compression depth (mm) was 44 +/− 9 versus 49 +/− 7 in the Koch scenario (p=0.01) (target 50 to 60). The mean percentage of compressions with complete release in the conventional scenario was 86 +/− 20 versus 84 +/− 22 in the Koch scenario (p=0.9) (target 100%). Using a Modified Borg Scale of 1 to 10, mean provider fatigue after conventional CPR was 7 (+/− 1.6) versus 3 (+/− 1.2) using Koch technique (p<0.001). On average, Koch technique improved the percentage of compressions at target rate by 26%, the percentage at correct depth by 9%, overall compression quality score by 13% and were more less fatiguing. Conclusion: Using an elbow in a height-restricted environment improved compression depth and reduced provider fatigue. From our limited data, Koch compressions appear to improve compression quality. Further study and external validation are required.

Introduction: Emergency Department Overcrowding (EDOC) is a multifactorial issue that leads to Access Block for patients needing emergency care. Identified as a national problem, patients presenting to a Canadian Emergency Department (ED) at a time of overcrowding have higher rates of admission to hospital and increased seven-day mortality. Using the well accepted input-throughput-output model to study EDOC, current research has focused on throughput as a measure of patient flow, reported as ED length of stay (LOS). In fact, ED LOS and ED beds occupied by inpatients are two “extremely important indicators of EDOC identified by a 2005 survey of Canadian ED directors. One proposed solution to improve ED throughput is to utilize a physician at triage (PAT) to rapidly assess newly arriving patients. In 2017, a pilot PAT program was trialed at Kelowna General Hospital (KGH), a tertiary care hospital, as part of a PDSA cycle. The aim was to mitigate EDOC by improving ED throughput by the end of 2018, to meet the national targets for ED LOS suggested in the 2013 CAEP position statement. Methods: During the fiscal periods 1-6 (April 1 to September 7, 2017) a PAT shift occurred daily from 1000-2200, over four long weekends. ED LOS, time to inpatient bed, time to physician initial assessment (PIA), number of British Columbia Ambulance Service (BCAS) offload delays, and number of patients who left without being seen (LWBS) were extracted from an administrative database. Results were retrospectively analyzed and compared to data from 1000-2200 of non-PAT trial days during the trial periods. Results: Median ED LOS decreased from 3.8 to 3.4 hours for high-acuity patients (CTAS 1-3), from 2.1 to 1.8 hours for low-acuity patients (CTAS 4-5), and from 9.3 to 8.0 hours for all admitted patients. During PAT trial weekends, there was a decrease in the average time to PIA by 65% (from 73 to 26 minutes for CTAS 2-5), average number of daily BCAS offload delays by 39% (from 2.3 to 1.4 delays per day), and number of patients who LWBS from 2.4% to 1.7%. Conclusion: The implementation of PAT was associated with improvements in all five measures of ED throughput, providing a potential solution for EDOC at KGH. ED LOS was reduced compared to non-PAT control days, successfully meeting the suggested national targets. PAT could improve efficiency, resulting in the ability to see more patients in the ED, and increase the quality and safety of ED practice. Next, we hope to prospectively evaluate PAT, continuing to analyze these process measures, perform a cost-benefit analysis, and formally assess ED staff and patient perceptions of the program.

Introduction: Pulmonary Embolism (PE) management in Emergency Department (ED) confers a substantial cost burden representing opportunities for improvements in decision-making. The Pulmonary Embolism Severity Index (PESI) is a validated tool to prognosticate patients with PE supporting admit versus (vs.) discharge decisions from the ED. Despite existing evidence, PESI is under-used in patients with PE. We sought to evaluate PESI scores and patient disposition from 4 EDs within Calgary to determine discordance between them and the effect of the discordance on readmission and mortality. Methods: Retrospective review of adult patients 18 years, diagnosed with PE between January-June 2016 at 4 EDs in Calgary Health Region. Patients were divided into high-risk PESI (score>85) and low-risk PESI (score 0-85). Chi-Square (2) test was used for comparison between the groups. Primary outcome measure was rate of discordance between PESI risk and disposition decision and identify factors driving the discordance. Secondary outcome measures included comparing 30-day readmission rate, 30-day and 90-day mortality between the discordant PESI groups. Results: 365 patients were diagnosed with PE in the study period with 60% being admitted and 40% discharged. The median PESI score in admitted patients was 85 (26-172) vs. 68 (20-163) in discharged patients. 51% of admitted patients had a low-risk PESI score and 24% of the discharged patients were high-risk PESI. 30-day readmission rate was 22.9% vs 5.3% (p=0.002) in discharged patients with high-risk PESI vs. discharged patients with low-risk PESI. Hypoxemia was the most common (62%) justification for admission in low-risk PESI groups. Among discharged patients we noted an 8.6% 90-day mortality in the high-risk vs. 0% in the low-risk PESI groups. Conclusion: Discharging a PE patient from the ED with a high PESI score carries a significant risk of ED revisit and readmission. Hypoxia was the reason for admission in majority of low risk PE patients.