Introduction: Laceration is common in children presenting to the emergency department (ED). They are often uncooperative related to pain and distressed during repair. Currently, there are wide variations regarding sedation and analgesia practices when sutures are required. There is a growing interest in the intranasal (IN) route for procedural sedation and pain control because of its effectiveness potential and ease of administration. Few studies have evaluated IN ketamine for procedural sedation in children with reported doses ranging from 3 to 9 mg/kg. The objective is to evaluate the optimal IN ketamine dose for effective and safe procedural sedation for laceration repair in children aged 1 to 12 years. Methods: A dose escalation clinical trial with an initial dose of 3 mg/kg of IN ketamine up to a maximum dose of 9 mg/kg in children 1 to 12 years old, using a 3+3 trial design. For each tested dose, 3 patients are enrolled. Escalation to the next dose is permitted if sedation is unsuccessful in at least one patient without serious adverse event (SAE). Regression to prior dose is warranted in the occurrence of two or more SEAs. This process is repeated until effective sedation for 6 patients at two consecutive doses is achieved with a maximum of 1 SAE or if regression occurs. The primary outcome is the optimal dose for successful procedural sedation as per the PERC/PECARN consensus criteria. Secondary outcome, namely, pain and anxiety levels, parent, patient and provider satisfaction, recovery time, length of stay in the ED, side effects and adverse event are recorded. Results: Nine patients have been recruited from March to December 2017 with median age of 2.9 years-old and with laceration length of 2 to 5 cm and with facial involvement in 55% of cases, respectively. Sedation was successful in 1/3, 1/3 and 3/3 of patients at doses of 3, 4, 5 mg/kg respectively, without any SAE. Median time from ketamine administration to return to baseline status and discharge were 35 and 98 min, respectively. We expect to complete patient recruitment in March 2018. Conclusion: The results from our trial is a groundwork for future dose-finding study. Pending study completion, a multicentric dose validation trial, is set up to further validate the optimal dose from dosINK1 trial. IN ketamine has the potential to improve the field of procedural sedation for children by introducing an effective IN agent with respiratory stability but without the need for an IV line insertion not otherwise needed.

Introduction: Hepatitis C virus (HCV) infection represents a significant public health problem in Canada and it is estimated that nearly half of individuals with chronic hepatitis C infection are unaware of their disease status. Previous studies of urban emergency department (ED) based screening programs have shown a prevalence ranging from 7.3 to 26% in high risk patients presenting to the ED . The advent of new treatment regimens with high rates of virologic cure strengthens the case for identifying the optimal setting for screening and testing individuals who may benefit from treatment. The proposed pilot project of ED-based screening for hepatitis C virus will aim to determine the prevalence of undiagnosed HCV infection and to link patients with chronic HCV infection to appropriate specialized follow-up care. Methods: We will be conducting a prospective cohort study of patients presenting to an urban emergency department between March and May 2018. Patients will be screened using high risk criteria for HCV infection as per national guidelines. Eligible patients will be offered and consented for a rapid point of care antibody test. Individuals with a positive antibody screen will have confirmatory testing and be linked to hepatology follow-up. The primary outcome will be the prevalence of hepatitis C virus among tested patients. Secondary outcomes will include the proportion of high risk patients without a primary care MD or access to alternate care settings where screening may occur, as well as the proportion of HCV-positive patients who are successfully linked to care. Results: We expect to screen approximately 2000 participants during the study period leading to an estimated 400 rapid antibody tests. Based on published results from other centres, we estimate that a significant proportion of screened patients will test positive for chronic HCV infection ( > 10%). Descriptive analyses will be performed for all variables using proportions with 95% confidence intervals. Conclusion: To our knowledge, no emergency department in Canada has undertaken protocoled HCV screening using rapid antibody testing in the ED. Results will inform the future development of integrated ED-based screening programs in novel settings more likely to be accessed by the at-risk population. Linking patients with chronic HCV infection to appropriate care will decrease the number of individuals developing HCV-related cirrhosis and hepatocellular carcinoma, thereby improving patient outcomes and reducing the future impact on our health care system.

Introduction: Lower gastrointestinal bleeding (LGIB) can result in serious adverse events, including recurrent bleeding, need for intervention and death. Endoscopy is important in the management of LGIB, however gastroenterologists have limited resources to safe endoscopy. Risk stratification of LGIB patients can aid physicians in disposition decisions. Objective: to develop a clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day serious adverse events. Methods: We conducted a health records review and included 372 adult ED patients who presented with an acute LGIB. The outcome was a 30-day composite outcome consisting of all-cause death, recurrent LGIB, need for intervention to control the bleed and ICU admission. A second researcher confirmed data-collection of 10% of the data and we calculated a -value for inter-rater reliability. We analyzed the data using stepwise backwards selection and SELECTION=SCORE option and calculated the diagnostic accuracy of the final model. Results: Age 75 years, hemoglobin 100 g/L, INR 2.0, a bloody stool in the ED and a past medical history of colorectal polyps were significant predictors in the multivariable regression analysis. The AUC was 0.83 (95% CI 0.77-0.89), sensitivity 0.96 (0.90-1.00), specificity 0.53 (0.48-0.59), and negative likelihood ratio 0.08 (0.02-0.30) for a cut-off score of 1. Conclusion: This model showed good ability to identify LGIB patients at low risk for adverse events as evidenced by the high AUC, sensitivity and negative likelihood ratio. Future, large prospective studies should be done to confirm the data, after which it should be validated and implemented.

Introduction: Safe and efficient handovers between emergency medical services (EMS) practitioners and emergency nurses are vital as poor transitions may lead to loss of information and place patients at risk for adverse events. We conducted a mixed methods systematic review to a) examine factors that disrupt or improve handovers from EMS practitioners to emergency department nurses, and b) investigate the effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. Methods: We searched electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); grey literature (grey literature databases, organization websites, querying experts in emergency medicine); and reference lists of the included studies. Citation tracking was conducted for the included studies. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the Joanna Briggs Institute Critic Appraisal Checklist for Qualitative Research. Narrative and thematic synthesis were conducted to integrate and explore relationships within the data. Results: Twenty-two studies were included in this review from the 6150 records initially retrieved. Our analysis suggests that qualitative, quantitative, and mixed methods research approaches have been utilized to explore handovers. Studies (n=11) have predominantly explored existing patterns of handovers focusing on barriers and facilitators. Interventions (e.g. multimedia transmission of pre-hospital information, tailored e-learning program) were investigated in five studies. Results suggest that lack of formal handover training, workflow interruptions, workload, and strained working relationships between EMS and nursing are perceived threats to optimal handovers. Conclusion: The findings from this review can inform the development of handover interventions and contribute to a more rigorous approach to researching handovers between EMS practitioners and emergency nurses. Furthermore, there is a need for studies in which specific interventions to optimize handovers are examined.

Introduction: Emergency physicians must achieve and maintain competence in numerous procedural skills, many of which are high stakes, time dependent, and used infrequently in clinical practice. Mental practice (MP) is the systematic use of mental imagery to see and feel an action in ones imagination without engaging in actual physical movement, and has been shown to enhance skill acquisition and performance in music and athletics. In this scoping review, we describe the utility and effectiveness of MP as a tool for procedural skill acquisition in medicine. Methods: An electronic search of MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, Open Grey, Conference Proceedings Index, ProQuest Dissertations and Theses and Google Scholar was conducted. Included studies evaluated MP for learning medically related technical skills using any method of mental training (script memorization, hypo-therapy, psychotherapy). Two independent reviewers screened articles for inclusion, and data was extracted using a standardized tool. Results: Our search returned 2028 results, of which 61 were eligible for inclusion. Forty-three studies evaluated MP interventions for technical skill development. Of these, 69.6% focused on minimally invasive surgical skills. The most common outcome measure was quantitative evaluation of skill via observer-scored checklist (69.6%). Other outcomes included stress, time to task completion, and haptic and movement data from surgical simulators. 82.6% of studies demonstrated a positive effect of MP on skill acquisition or performance. The quality of the trials was modest, and only 34.7% of published work provided clear detail on specific MP strategies. Conclusion: MP is an effective tool for procedural skills training. Areas outside of minimally invasive surgery are under-represented, and more data is needed on MP for rare or emergent procedures that typify emergency care. The minority of studies reviewed reported methods for developing and validating MP interventions in sufficient detail, a practice that should be adopted in future trials.

Introduction: During a hockey game, athletes who are suspected of having sustained a concussion are removed from the game and evaluated. The modified balance error scoring system (MBESS) assessment, an essential part of the concussion evaluation, is performed in the dressing room, barefoot on a hard surface after equipment removal. While, players that pass the concussion assessment may re-dress and return to play, the equipment removal and re-dressing delays their return into the game. The objective of our study was to develop and evaluate a new in-skates balance error scoring system (SBESS) to reduce the delay in returning to the game. Methods: A prospective randomized single blinded study was conducted with 80 healthy university hockey players split into two groups. An at-rest group performed the SBESS assessment at rest on two separate occasions. A post-exercise group performed the test once at rest and once after exercise. The SBESS consisted of performing 4 different stances for 20 seconds each without equipment removal. The assessments were video recorded, and 3 independent reviewers scored the videos. For both the at-rest and post-exercise groups, the primary outcome measured was the number of balance errors. The secondary outcome was the number of falls. Statistics: For the primary outcome, both inter-rater and intra-rater reliability were calculated. The concordance between the SBESS and the currently used baseline pre-season balance score (MBESS) was also assessed. Results: The number of cumulative balance errors for all four stances varied between 4 and 7 for both groups without any significant exercise effect. No athletes fell. For inter-rater reliability, the intra-class correlation (ICC) was above 0.86, ranging from 0.86-0.92 for most stances except for the easiest stance, for which it was 0.66. For intra-rater reliability, the ICC ranged from 0.88 to 1 for all stances and raters. There was a lack of concordance between the SBESS and MBESS. Conclusion: The SBESS is a reliable balance test that can be safely performed in healthy athletes wearing their full equipment. The next step will be to evaluate the use of this test on concussed hockey athletes

Introduction: Traditionally, out of hospital cardiac arrests (CA) have poor outcomes. Incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly to supplement ACLS to provide better outcomes for patients. Current literature suggests potentially improved outcomes, including neurological function. We assessed the feasibility of introduction of ECPR to a regional hospital using a 4-phase study. We report phase-1, an estimation of the number of potential candidates for ECPR in our setting. Methods: Following development and agreement on local criteria for selection of patients for ECPR using a modified Delphi Technique, inclusion and exclusion criteria were applied retrospectively, to a database comprising 4 years of emergency department (ED) cardiac arrests (n=395). This provided estimates of the number of patients who would have qualified for EMS transport for ECPR and initiation of ECPR in the ED. Results: Application of criteria would result in 20.0% (95% CI 16.2-24.3%) of CA being transported to the ED for ECPR (mean 18.5 patients per year). In the ED 4.6% (95% CI 2.83-7.26%) would be eligible to receive ECPR (4.3 patients per year). Incorporating downtime criteria, 3.0% (95% CI 1.6-5.3%) qualify. After considering local in-house cardiac catheterization hours 9.4% (95% CI 6.8-12.9%) and 5.4% (95% CI 3.5-8.2%), without and with EMS rhythm assumptions respectively, would be eligible for transport. For placement on pump, 3.0% (95% CI 1.6-5.3%) and 2.4% (95% CI 1.2-4.6%), without and with use of total downtime respectively, were eligible. Conclusion: If historical patterns of CA were to continue, we believe that an ECPR program may be feasible in our regional hospital setting, with a small number of selected cardiac arrest patients meeting eligibility for transportation and initiation of ECPR. These numbers suggest that an ECPR program would not be resource intensive, yet would be sufficiently busy to maintain adequate team competency.

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.

Introduction: Patients with new onset and chronic atrial fibrillation and/or flutter (AFF) present to emergency departments (ED) with symptoms requiring acute management decisions. Most research has focused on patients with acute (<48 hours and/or <7 days with adequate anticoagulation) presentations of AFF and for whom rhythm control is considered safe. This study explored the demographic characteristics, risk factors, anticoagulant/anti-platelet prescription, and outcomes for patients with symptomatic AFF. Methods: A convenience sample of adult patients presenting to the one of three hospitals affiliated with the University of Alberta with symptoms of acute AFF were enrolled, within a fee-for-service billing environment. Following informed consent, a trained researcher administered a survey to each patient, recorded administrative details (e.g., triage, times, laboratory tests) 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 (t-tests, chi-square) statistics are presented for continuous and dichotomous outcomes, respectively. Results: Overall, 217 patients were enrolled; the median age was 64 (IQR: 55, 73) and 132 (61%) were male. Overall, 42 (19.4%) patients arrived by ambulance; 8 (4%) spontaneously converted or were diagnosed with another arrhythmia between arrival and obtaining an ECG. A prior history of AFF was common 152 (71%), as were the following cardiovascular and other risk factors: 176 (81.1%) consumed alcohol, 104 (48%) were current or former smokers, 86 (39.6%) had hypertension, 22 (10%) had CAD, and 10 (5%) had COPD. These patients most commonly reported palpitations 183 (84%) as their dominant symptom. Anti-platelets and anticoagulants were common prior to the ED 145 (67%), and 36 (17%) of patients were discharged from the ED without one of these medications. Overall, 80 (37%) patients had chronic AFF or an unknown timeline; no efforts were made to restore NSR in these patients. A dominant pattern for electrical cardioversion was observed; of 129 cases where cardioversion was attempted, 84 (65%) had electrical first and 45 (35%) had chemical first cardioversion attempts. Overall, 22 (49%) of 45 patients receiving chemical first were successfully converted to NSR. Patients with AFF history who were cardioverted were less likely hospitalized than those not-cardioverted (3% vs. 16%, p=0.006); 21 (10%) were admitted to hospital. Conclusion: In this center, patients with AFF often present to the ED with high acuity, with severe symptoms and receive aggressive care. The use of anticoagulants suggests an appreciation of thrombo-embolic risks, both in the community and ED settings. Like many EDs, this center appears to have a signature for AFF management, related to evidence gaps, physician preferences, and perhaps funding models.

Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is widely recognized as a major contributor to overcrowding, particularly in very high-volume hospitals. The issue of bed boarding is directly tied to hospital-wide capacity, flow and operations. Early morning discharge from inpatient units has been identified as a low-cost intervention to decrease bed boarding, as it allows earlier transfer of admitted patients from the ED. Several hospitals have instituted discharge before noon, or discharge before 10AM policies, practices and targets. Our objectives were 1) to assess the current status of flow within 3 high-volume community hospitals with respect to time of day of discharges from the in-patient units and time of day of transfers from the ED to in-patient units, and 2) to assess the association between time of transfer from the ED and total ED Length of Stay (EDLOS) of admitted patients. Methods: We conducted a retrospective multi-centre observational study during the period of January 1, 2015 to December 31, 2015 at three high-volume community hospitals within Ontario, Canada. All patients admitted to the Medicine service were identified. Time of discharge from the in-patient units and time of transfer from the ED were collected for all patients. EDLOS was calculated for all patients as a function of time of transfer from the ED. Results: Preliminary findings show that, for the three community hospitals, only 11.7% - 19.6% of admitted patients were discharged from the in-patient units during the period between 6AM and 12PM, with a peak discharge time of 2PM in all three hospitals. A concurrent lag was observed in the time of transfer of patients from the ED, with peak transfer times occurring the late afternoon between 3PM and 9PM, and coinciding with a peak in patient volume in the ED. Patients transferred out of the ED earlier in the day (between 12AM 11:59AM) had between 1.4 hours to 8.0 hours lower mean EDLOS when compared to those patients transferred later in the day (between 12PM 11:59PM). Conclusion: Hospital-wide flow and operational issues have a significant impact on ED bed boarding, and potential efficiencies seem at the current time to be underutilized. Interventions aimed at optimizing flow must be implemented alongside those aimed at increasing capacity in order to improve bed boarding. ** These findings are best communicated in graphic form to better represent the dynamics of the flow in and out of the ED over a 24-hour period, and will be presented in graphic format if selected for the conference.

Introduction: The increased availability and increased utilization of Computed Tomography (CT) imaging as a diagnostic tool has in the past several years led to concerns regarding the unknown and potentially harmful effects of ionizing radiation exposure to patients, as well as the increased cost to the health care system. Multiple education campaigns (e.g. Choosing Wisely) and institution-wide interventions have been implemented in order to limit the use of potentially unnecessary CT imaging. Two specific modalities CT head and CT angiography to rule out pulmonary embolism (CT PE) have been identified as potential targets of these interventions due to their likely overutilization in the clinical ED setting. The objective of this study was to determine the interphysician variability in the ordering rates of CT head and CT PE, and to determine if any correlation existed between CT head and CT PE ordering rates among physicians. Methods: Data was collected on all diagnostic imaging ordered by ED physicians at two very high volume community hospitals during the 4-year period between 2013 and 2016. Analysis was limited to those physicians who worked at least 3 of the 4 years at either site and saw at least 1000 patients per year. The ordering rates for each physician were calculated by dividing the number of the imaging modality ordered over the total number of patients seen. Correlation coefficients (r values) were calculated to determine if a linear correlation existed between increased CT head and increased CT PE ordering rates. Results: The DI ordering data for a total of 44 ED physicians were analyzed. Results show average 4-year ordering rates for CT heads among ED physicians ranging from 4.0% to 13.9%, and CT PE ordering rates ranging from 0.1% - 1.7%. The correlation coefficient between CT head and CT PE ordering rates was positive for all 4 years, with a statistically significant (p<0.05) correlation coefficient of 0.53. Conclusion: There is a wide degree of variability in DI ordering patterns among physicians working within the same clinical environment. Further exploration of this interphysician variability will be helpful in designing strategies to mitigate overutilization of diagnostic imaging.

Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is one of the major contributors to ED overcrowding, and an indicator of hospital-wide deficiencies in capacity and flow. Most indicators of ED overcrowding have measured either counts or percentages of patient subgroups (e.g. number/percentage of patients waiting in triage or number/percentage of admitted patients as compared to full ED census), or specific process time intervals related to patient movement through the hospital (e.g. Physician to Initial Assessment (PIA) time or total ED Length of Stay (EDLOS)). We sought to 1) devise an alternative measure of ED overcrowding that captured the dynamic and disproportionate resource utilization of admitted versus non-admitted patients in the ED, and to 2) determine the association of this measure with selected ED quality metrics for non-admitted patients. Methods: We conducted a retrospective multi-centre observational study at three very high-volume community hospitals in the Greater Toronto Area. Data on all patients visiting the ED during the period between January 1, 2015 and December 31, 2016 were included in the study. We calculated the total daily cumulative boarding time - or time to bed (TTB) - for each day of the study duration. The daily cumulative TTB was calculated as the time from decision to admit to transfer from the ED for all admitted patients within a 24-hour period. We conducted linear regression analysis to determine the association between our measured daily cumulative TTB and daily median and 90th percentile PIA and EDLOS times for non-admitted patients. Results: Preliminary results for 2015 indicate a total cumulative TTB time ranging from 50,973 hours to 191,093 patient-hours for the year, with daily mean cumulative TTB ranging from 140 524 patient-hours/day among the three hospitals. In all three hospitals, there was a statistically significant (p<0.01) positive association between daily cumulative TTB and both median and 90th percentile PIA times for all patients, and median EDLOS times for non-admitted CTAS 1 -3 patients. There was a statistically significant (p<0.05) positive association between daily cumulative TTB and 90th percentile EDLOS for non-admitted CTAS 1-3 patients in two of the three hospitals, with the third hospital showing a positive but non-significant association. Conclusion: Bed boarding constitutes a significant resource cost for EDs, and has a negative impact on timeliness of ED care for the general ED population, particularly more complex (CTAS 1-3) non-admitted patients.

Introduction: It is assumed that sexual assault cases presenting at Emergency Departments (ED) are frequently lost to follow-up and should be considered an eligible population for presumptive antimicrobial treatment of sexual transmitted infections (STIs) at initial assessment without lab confirmation. With the growing burden of antibiotic resistance, antimicrobial stewardship guidelines caution against this practice. Among sexual assault cases, our study evaluated STI prevalence, follow-up and retention patterns, and described the prevalence of STI presumptive treatment. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital is the only program in Ottawa offering emergency and forensic care for survivors of sexual assault and domestic violence. Descriptive statistics were used to summarize information on demographics, clinical presentation, STI testing and results using data from the SAPACP case registry (January 1 - December 31, 2015). Results: Among the 406 patients seen by the SAPACP, there were 262 (64.5%) sexual assault cases that were included in this analysis. STI testing was completed for 209 (79.8%) patients at the initial visit, 90 (43.1%) completed via urine nucleic acid testing (NAAT), 140 (67.0%) via culture swab and 20 (9.6%) via both. Laboratory results detected no cases of gonorrhea, 8 (3.8%) cases of chlamydia, 33(15.8%) cases of bacterial vaginosis (BV), 17 (8.1%) cases of yeast vaginitis and 16 (7.7%) indeterminate testing results. Antimicrobial STI presumptive treatment was given to 12 (5.7%) patients at the time of their initial visit prior to lab confirmation. Patient follow-up occurred in 172 (82.3%) patients, with all chlamydia cases treated. Of the 37 (17.7%) patients lost to follow up, 9 were positive for BV, 1 was positive for yeast and 10 were indeterminate, all of which may be underlying vaginal flora. Follow up testing/test of cure was completed in 91 (52.9%) of patients, with 4 (2.3%) positive results, all of which were BV. Conclusion: In our ED, up to 15.8% of sexual assault patients had at least one laboratory confirmed STI and over 80% of all patients returned for follow-up. Our results show that it is safe and effective to only treat STI screen positive cases at follow-up, reducing the frequency of presumptive antimicrobial STI treatment. Benefits of this strategy include decreased patient side effects, cost savings and better antimicrobial stewardship.

Introduction: Upper gastrointestinal bleeding (UGIB) is a common Emergency Department (ED) presentation. Early endoscopic intervention, supported by Glasgow Blatchford Score (GBS) severity, has been shown to reduce re-bleeding rates and lower morbidity and mortality. However, emergent endoscopy is not necessary for all patients. Low-risk patients can be managed with outpatient follow-up. Other important management decisions such as blood transfusion (Hb <70) and use of proton pump inhibitors (PPI) also warrant evaluation. The aim of this study was to compare the timing and appropriateness of endoscopy and blood transfusion and proton pump inhibitor (PPI) use in a tertiary care setting to the standard of care. Methods: A retrospective cohort study was conducted to examine the management of patients presenting with UGIB to the ED in 2016 using a standard chart review methodology. TANDEM and EDIS (Emergency Department Information System) databases were queried to identify patients using specified ICD 10 codes and the CEDIS (Canadian Emergency Department Information System) presenting complaints of vomiting blood or blood in stool/melena. Outcome measures included: patient characteristics, the GBS to determine appropriateness of endoscopic intervention, diagnoses, blood transfusion indications and utilization of oral or intravenous PPIs. Data were entered into a REDCap database and analyzed using standard non-parametric statistical tests. Results: A total of 200 patients, 59% male (118/200), mean age 59 years (range 18 - 92 years) were included. The median GBS was 9. 79% of patients (157/200) underwent endoscopy during the hospital visit: 30% of patients with GBS 0-3 (13/43) and 80% patients with GBS 4 (125/157) underwent endoscopy 24 hours. The two most common endoscopic diagnoses were peptic ulcers (39%, 61/157) and varices (18%, 28/157), while 14% (22/157) had a normal diagnosis or mild gastritis. 174/200 patients (87%) were given IV or oral PPI in the ED whereas the remaining 26 (13%) did not receive PPI in hospital. 46% of patients (89/194) received blood transfusion, but only 51% (45/89) were administered based on the 70 g/L threshold while in 40% (36/89) of patients the less restrictive threshold of 90 g/L was used. Conclusion: A majority of UGIB patients presenting to a tertiary hospital ED appropriately received endoscopy 24 hours based on a GBS score 4. PPI use was appropriate but a proportion of patients received inappropriate blood transfusions.

Introduction: On March 16 2017, emergency departments and urgent care centres (collectively, EDs) in Calgary saw 3 times the number of fall-related ED visits, and 8 times the number of ED orthopedic consultations and admissions than the daily average for March 2014-2016. Fall-related injuries have significant associated morbidity and burden of disease, as well as cost to the health care system, caregivers and society. The purpose of this study was to use regression analysis to generate best fit models and identify weather and temporal variables which predict the frequency of fall-related ED visits, orthopedic consultations and admissions in winter (November-March). Methods: Daily number of ED visits, orthopedic consults, and orthopedic admissions for presenting complaint of Lower Extremity Injury, Upper Extremity Injury, or with an ED diagnosis of Fracture or Fall, were obtained for winter months from November 1 2013 to March 31 2017 from the Alberta Health Services ED database. Weather data was obtained from Environment Canada. Linear and multiple regression were performed to evaluate the predictive value of individual weather and temporal parameters, and derive the best-fitting model to predict the number of ED visits, orthopedic consultations, and orthopedic admissions. Results: Individual predictive factors (p<0.05) were month, temperature, overnight temperature drop from >0C to <0C, day of the week, amount of snow on the ground at 05:00, post-chinook day (chinooks are a warm winter wind in Calgary that can cause large temperature swings), maximum wind gust speed, and presence of precipitation. The best-fit multivariable models predicting fall-related ED visits (F-stat=15.36, R2=0.171), orthopedic consults (F-stat=6.369, R2=0.048), and orthopedic admissions (F-stat=8.658, R2=0.126) were statistically significant (probability of F-statistics all <0.0001). Conclusion: This study is, to the best of our knowledge, the first to use multiple regression to compute models using weather and temporal variables that can predict fall-related ED visits, orthopedic consults and admissions. This information could be used to alert the population regarding an increased fall and fracture risk ahead of the weather occurrence, as well as municipal snow and ice clearing services, who may be able to mitigate that risk. The ability to predict the frequency of fall-related injuries could enable EDs, EMS, orthopedic services, and hospitals to adjust resource and staffing allocation in anticipation of increases in fall-related injuries.

Introduction: Teamwork skills are essential in emergency presentations. When training medical students to manage acute care cases, simulation is frequently the educational tool. However, simulation content is often medically-focused, and post-simulation debriefs may not prioritize discussion of teamwork skills, as time is limited. Furthermore, debriefing both medical and teamwork aspects of a case may add to the learners cognitive load. This innovation uses an escape game as a non-clinical simulation to gamify teamwork skills training, with a focus on the collaborator CanMEDS role. In the entertainment industry, escape games are activities where teams solve a series of puzzles together to ultimately escape a room. Methods: 2 groups of 5 second-year medical students piloted the escape game, created within a simulation theatre, designed to surface teamwork competencies under the four University of Calgary Team Scheme domains (adapted from CIHCs National Interprofessional Competency Framework and TeamSTEPPS): Leadership/Membership, Communication, Situation Monitoring, and Collaborative Decision-Making/Mutual Support. During the game, facilitators noted examples of students strengths and challenges in demonstrating teamwork competencies. Post-game, a debrief and written reflective exercise enabled students to analyze successes and challenges in demonstrating teamwork competencies, propose solutions to teamwork challenges, and write 3 goals to improve teamwork skills. All competencies listed under each Team Scheme domain represented themes used in a thematic analysis to uncover students reported teamwork challenges. Results: Each escape game is a 30-minute teamwork activity where 5 students collaborate to complete 8 puzzles, which do not require medical knowledge, in order to win. Briefing is scheduled for 15-minutes, whereas post-game debriefing and reflection is 45-minutes. Conclusion: Escape games can highlight strengths and challenges in teamwork and collaboration amongst second-year medical students. Every competency under the Team Scheme domains was highlighted by the escape game pilots, touching on both strengths and challenges, for which students demonstrated, debriefed, and reflected upon. Students self-documented teamwork challenges include issues surrounding task-focused, closed-loop communication, and frequent reassessments. Advantages of this innovation include its use as a learning progression towards acute care simulations, portability and affordability, potential interprofessional use, and customizability. Additional training time may be required to orient facilitators to this atypical simulation. The escape game will launch in MDCN490 for second-year medical students and is scheduled prior to their acute care simulations. Further teamwork challenges identified at that time will help inform teamwork curriculum development for year 3.

Introduction: Substance and opioid misuse present significant illness burdens in Emergency Departments (EDs). Understanding risk factors for mortality in these patients is urgently needed to allow targeted prevention. This studys objective was to determine whether frequent ED use is independently associated with mortality among patients with substance and opioid misuse, and secondarily, whether degree of frequent use influences mortality risk. Methods: This is a retrospective cohort study in Alberta, Canada. National Ambulatory Care Reporting System ED data was linked to Vital Statistics mortality data using postal code, birthdate, and sex. All adults (18 years old at index visit, i.e. first visit made in the study year) with substance or opioid misuse (defined by ICD-10 codes) from April 1, 2012 to March 31, 2013 were included. Frequent use was defined by 5 ED visits in the 12 months prior to index visit. The primary outcome was mortality within 90 days, and secondarily, within 30 days, 365 days, and 2 years post-index visit. Mortality was compared using Kaplan-Meier curves and Cox regression adjusting for age, sex and income. Degree was examined by subcategorizing frequent use into 5-10, 11-15, 16-20, and >20 visits. Results: Overall, 16,389 patients made 24,880 visits for substance misuse, and 1787 patients made 2241 visits for opioid misuse. Frequent vs. non-frequent substance misusers were older, more often female, lower income, more often of rural residence, and arrived more by ambulance for lower acuity visits that were hospitalized less often. Compared to frequent substance misusers, frequent opioid misusers were more often female, of non-rural residence, arrived less often by ambulance, and made higher acuity visits that were hospitalized more often. Among substance misuse patients, 97.1% (95% CI: 96.6, 97.7) of frequent users vs. 98.0% (95% CI: 97.7, 98.2) of non-frequent users were alive at 2 years. Frequent use was significantly associated with mortality at 365 days (HR 1.36 [95% CI: 1.04, 1.77]) and 2 years (HR 1.32 [95% CI: 1.04, 1.67]) but not at 90 or 30 days. Subcategorized by degree, frequent use was significantly associated with mortality only for patients with >20 visits/year at 365 days (HR 1.88 [1.03, 3.44]) and 2 years (HR 1.89 [1.10, 3.22]). Among opioid misuse patients, there was no difference in mortality between frequent and non-frequent ED users at any time point. However, subcategorized by degree, a significant association was seen for those with 16-20 visits/year at 365 days (HR 3.62 [95% CI:1.13, 11.66]), and 2 years (HR 3.37 [95% CI: 1.05, 10.81]). Conclusion: In substance misuse patients, frequent ED use was significantly associated with long-term but not short-term mortality. Mortality risk for substance and opioid misuse patients was concentrated in extremely frequent users suggesting that the highest frequency presenters should be targeted for prevention.

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) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm 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 and those without a D-dimer test 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 false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.

Introduction: At Sunnybrook Health Sciences Centres Emergency Department (ED), delays occurred in reporting positive microbiology culture results of patients discharged from the ED. Follow-up of culture results was driven by a manual paper based process that was inefficient and resulted in a one to three day delay in reporting results. The previous system was time consuming, labour intensive and prone to human error. Timely reporting of microbiology culture results is important to ensuring that patients receive optimal care. The aim is that >80% of positive microbiology culture results of patients discharged from Sunnybrook Health Sciences Centre ED will be followed-up within 24 hours of results being available from the lab. Methods: Outcome Measure Percentage of positive culture results followed up within 24 hours Process Measure Time from availability of culture results from lab to completion of patient follow-up Balancing Measure Number of positive culture results not displayed in ED server Change Idea Electronically push positive culture results to an ED server that is periodically checked daily and acted upon. An electronic interface was created to capture positive results from the microbiology lab in real time. Results: There was a 45 hour reduction in the mean time to complete a patients follow-up of culture results (59 hours pre vs. 14 hours post, p=0.03). We surpassed our aim of >80% follow-up within 24 hours. Conclusion: A significant reduction to completing a patients follow-up of microbiology culture results was achieved by automating the availability of results and eliminating the manual process previously used in relaying results from the microbiology lab to ED. This new process has the following benefits: 1) Improves timely reporting of culture results to patients, that may require initiation or change in antibiotics 2) Enhanced patient safety due to elimination of human error 3) Decreased workload due to elimination of batching of results and data entry 4) Entire process is streamlined, since only positive culture results are transmitted for follow-up.

Introduction: Competency-based medical education (CBME) affirms that trainees will receive timely assessments and effective feedback about their clinical performance, which has inevitably raised concerns about assessment burden. Therefore, we need ways of generating assessments that do not rely exclusively on faculty-produced reports. The main object of this research is to investigate how data already collected in the electronic health record (EHR) might be meaningfully and appropriately used for assessing emergency medicine (EM) trainees independent and interdependent clinical performance. This study represents the first step in exploring what EHR data might be utilized to monitor and assess trainees clinical performance Methods: Following constructivist grounded theory, individual semi-structured interviews were conducted with 10 EM faculty and 11 EM trainees, across all postgraduate years, to identify EHR performance indicators that represent EM trainees independent and interdependent clinical actions and decisions. Participants were presented with a list of performance indicators and asked to comment on how valuable each would be in assessing trainee performance. Data analysis employed constant comparative inductive methods and occured throughout data collection. Results: Participants created, refined, and eliminated performance indicators. Our main result is a catalogue of clinical performance indicators, described by our participants, as reflecting independent and/or interdependent EM trainee performance that are believed to be captured within the EHR. Such independent indicators include: number of patients seen (according to CTAS levels), turnaround time between when a patient is signed up for and first orders are made, number of narcotics prescribed. Meanwhile, interdependent indicators include, but are not limited to, length of stay, bounce-back rates, ordering practices, and time to fluids. Conclusion: Our findings document a process for developing EM trainee report cards that incorporate the perspectives of clinical faculty and trainees. Our work has important implications for distinguishing between independent and interdependent clinical performance indicators.