Introduction: Cognitive bias is often cited as an explanation for diagnostic errors. Of the numerous cognitive biases currently discussed in the literature, availability bias, defined as the current case reminds you of a recent similar example is most well-known. Despite the ubiquity of cognitive biases in medical and popular literature, there is surprisingly little evidence to substantiate these claims. The present study sought to measure the influence of availability bias and identify contributing factors that may increase susceptibility to the influence of a recent similar case. Methods: To investigate the role of prior examples and category priming on diagnostic error at different levels of expertise, we devised a 2 phase experiment. The experimental intervention was in a validation phase preceding the test, where participants were asked to verify a diagnosis which was either i) representative of Diagnosis A, and similar to a test case, ii) representative of Diagnosis A and dissimilar to a test case, iii) representative of Diagnosis B and similar to a test case. The test phase consisted of 8 written cases, each with two approximately equally likely diagnoses(A or B). Each participant verified 2 cases from each condition, for a total of 6. They then diagnosed all 8 test cases; the remaining 2 test cases had no prior example. All cases were counterbalanced across conditions. Comparison between Condition i) and ii) and no prior showed effect of prior exemplar; comparison between iii) and no prior showed effect of category priming. Because cases were designed so that both Diagnosis A and B were likely, overall accuracy was measured as the sum of proportion of cases in which either was selected. Subjects were emergency medicine staff (n=40), residents (n=39) and medical students (n=32) from McMaster University, University of Washington, and Harvard Medical School. Results: Overall, staff had an accuracy (A + B) of 98%, residents 98% and students 85% (F=35.6,p<.0001). For residents and staff there was no effect of condition (all mean accuracies 97% to 100%); for students there was a clear effect of category priming, with accuracy of 84% for i), 87% for ii) and 94% for iii) but only 73% for the no prime condition (Interaction F= 3.54, p<.002) Conclusion: Although prior research has shown substantial biasing effects of availability, primarily in cases requiring visual diagnosis, the present study has shown such effects only for novices (medical students). Possible explanations need to be explored. Nevertheless, our study shows that with increasing expertise, availability may not be a source of error.

Introduction: Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes such as recurrent ED visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (< 25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level > 20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate > 110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up.

Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &/or history of fever and 2 or more signs of hypoperfusion (eg. SBP<90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index >1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.

Introduction: Pulmonary embolism (PE) is a diagnostic challenge, since it shares symptoms with other conditions. Missed diagnosis puts patients at a risk of a potentially fatal outcome, while false positive results leave them at risk of side effects (bleeding) from unnecessary treatment. Diagnosis involves a multi-step pathway consisting of clinical prediction rules (CPRs), laboratory testing, and diagnostic imaging, but the best strategy in the Canadian context is unclear. Methods: We carried out a systematic review of the diagnostic accuracy, clinical utility, and safety of diagnostic pathways, CPRs, and diagnostic imaging for the diagnosis of PE. Clinical prediction rules were studied by an overview of systematic reviews, and pathways and diagnostic imaging by a primary systematic review. Where feasible, a diagnostic test meta-analysis was conducted, with statistical adjustment for the use of variable and imperfect reference standards across studies. Results: The Wells CPR rule showed greater specificity than the Geneva, but the relative sensitivities were undetermined. Application of a CPR followed by with D-dimer laboratory testing can safely rule out PE. In diagnostic test accuracy meta-analysis, computed tomography (CT) (sensitivity 0.973, 95% CrI 0.921 to 1.00) and ventilation/perfusion single-photon emission CT (VQ-SPECT) (sensitivity 0.974, 95% CrI 0.898 to 1.00) had the highest sensitivity) and CT the highest specificity (0.987, 95% CrI 0.958 to 1.00). VQ and VQ-SPECT had a higher proportion of indeterminate studies, while VQ and VQ-SPECT involved lower radiation exposure than CT. Conclusion: CPR and D-dimer testing can be used to avoid unnecessary imaging. CT is the most accurate single modality, but radiation risk must be assessed. These findings, in conjunction with a recent health technology assessment, may help to inform clinical practice and guidelines.

Introduction: The GridlockED game is a serious game aimed at teaching junior learners about flow and organization in the emergency department(ED). With serious games, the mechanism of learning is thought to be via the gameplay experience. Objectives built into gameplay are aimed at teaching players about a specific concept; in this case, we hoped to teach players about interprofessional collaboration and basic mechanics that drive flow in the ED. However, before a player can be taught, he or she must be engaged and have a positive gameplay experience. From the GridlockED gameplay, we aim to explore how a players gameplay experience related to observed actions while playing the game, including participating in decision making and keeping the team organized. Methods: From April-August 2017, participants were invited to play 4 turns of a GridlockED game session. They were video recorded during gameplay. After playing the game, they were surveyed using the previously derived Game Experience Questionnaire (GEQ) to measure their gameplay experience. The videos were reviewed by two research team members (SH, EJ), tallying various observed game actions. We conducted Pearson correlation between players GEQ total score and their observed actions. Results: A total of 32 participants (13 attendings, 5 senior residents, 10 junior residents, and 4 nurses) played the game. The average total GEQ was 67.2/132 (SD=10.7), suggesting most players had a moderately good gameplay experience. The total GEQ score correlated with component subscores within the questionnaire. Overall observed activity correlated well with each observed action subtype. However, the GEQ total score did not correlate significantly with the total observed action (Pearsons r=0.18,p=0.32). GEQ total score was found to be moderately correlated to an observation that a player participated in determining strategy during gameplay (r=0.36,p=0.04). There was a moderate negative correlation between determining strategy during gameplay and teaching about the game (r=-0.37,p=0.04) or emergency medicine concepts (r=-0.47,p<0.01). Conclusion: The GEQ is internally consistent, but does not have a strong relationship to observed actions, suggesting that game experience does not necessarily correlate with observable actions. This suggests that players may be intellectually stimulated or engaged without necessarily completing any observable actions during gameplay.

Introduction: The CAEP annual meeting presents the latest evidence for clinical practice, but there has not yet been an appraisal of the abstracts presented at this conference. Therefore, we sought to evaluate the level of evidence of research presented at the annual meeting, and assess for trends over a five-year period (2013-2017). Methods: We conducted a scoping review that included all CAEP abstracts from 2013-2017, obtained through the Canadian Journal of Emergency Medicine. Two reviewers assessed eligibility and extracted data from abstracts individually, with conflicts resolved by a third reviewer. Qualitative research was excluded. Extracted data included type of presentation (ex. oral, poster), sample size, study design and type of study (therapeutic, prognostic, diagnostic, education, quality improvement, or systems-wide/economic analyses research). A level of evidence (LOE) was assigned using the 2011 Oxford Centre for Evidence-Based Medicine criteria. Results: Abstracts from 2014-2017 have been analyzed thus far, 1090 of which were eligible and 990 included. Inter-rater agreement for screening and data extraction was high ( value 0.87 and 0.84 respectively). Systems-wide/economic analyses research was the predominant type of study (28.6%, 283/990), followed by therapeutic (19.9%, 197/990) and education (19.9%, 195/990). The mean LOE was 2.81 (95% CI 2.77,2.85). The highest proportion of studies were of level III evidence (77.7%, 769/990), followed by level II (9.6%, 95/990) and level I evidence (7.8%, 77/990). 72.1% (124/172) of all level I and II abstracts were presented in 2016 and 2017. A significant change in LOE between years was evident (p<0.0001, chi-squared). The greatest proportion of level I and II abstracts were lightning oral (41.9%, 72/172), followed by posters (36.0%, 62/172). The best average LOE was observed for lightning oral (2.64, 95% CI 2.56, 2.72), with the poorest average LOE witnessed for moderated posters (2.90, 95% CI 2.83, 2.97). A significant difference was present in mean LOE between types of presentations (p<0.0001, one-sided ANOVA). Conclusion: The majority of abstracts were level III evidence. The lightning oral sessions had the greatest proportion of level I and II evidence presented. Recent years of the conference have also seen the presentation of a greater number of level I and II evidence, which may suggest a shift towards generating and disseminating higher level evidence in emergency medicine.

Introduction: Prior research has shown that audit and feedback (A &F) can be an effective tool for practice change. However, questions remain about how to optimize A&F. The objectives of this project were to determine if: 1) there are differences in practice between physicians who do, and do not, consent to receive a confidential report on their practice and; 2) if there is a relationship between consenting physicians self-predicted and actual practice. Methods: This was a prospective, cross-sectional study embedded in a larger quality improvement (QI) initiative to align physician practice with best evidence in the emergency department (ED) care of infants with bronchiolitis. All physicians practicing in the ED of a tertiary care pediatric hospital were offered the opportunity to consent to receive an individual, confidential data report on their practice. Prior to receiving their data, consenting physicians completed a survey which asked them to predict the proportion of bronchiolitic patients for whom they ordered diagnostic tests or treatments. We used chi-squared testing to compare the proportion of consenting and non-consenting physicians whose diagnostic test (Chest X-ray (CXR), viral study) and treatment (steroid, Ventolin) ordering was above the median for all ED physicians. We used Pearsons correlation to assess the relationship between consenting physicians self -predicted and actual practice. Results: 56% (37/66) of physicians consented to receive a data report. The median proportion of patients with an x-ray ordered was 20%, 63% of non-consenters were above the median, compared to 36% of consenters (X2 (1, N=66)=4.91 p=0.03). For viral testing, 31% of patients had a test ordered, with 50% of non-consenters and 50% consenters above the median (( X2 (1, N=66) =0 p=1); 11% of patients had steroids ordered, with 53% of non-consenters and 47% of consenters above the median ( X2 (1, N=66)=0.24 p-0.621); and 18% of patients had Ventolin ordered, with 60% of non-consenters and 42% of consenters above the median ( X2 (1, N=66) =2.2 p=0.138). There was a moderate correlation between physicians predicted and actual practice with respect to viral testing (r=0.67), but minimal correlation for CXR (0.05), steroids (r=0.17) or Ventolin (r=0.33) ordering. Conclusion: The finding that physicians have a limited ability to accurately predict their own performance emphasizes the importance of providing physicians with feedback. However, our results suggest that the consent process may be a potential barrier to effective A &F.

Introduction: Screening for organ and tissue donation is an essential skill for emergency physicians. In 2015, 4564 individuals were on a waiting list for organ transplant and 242 died while waiting. As Canadas donation rates are less than half that of other comparable countries, it is crucial to ensure we are identifying all potential donors. Patients deceased from poisoning are a source that may not be considered for referral as often as those who die from other causes. This study aims to identify if patients dying from poisoning represent an under-referred group and determine what physician characteristics influence referral decisions. Methods: In this cross-sectional unidirectional survey study, physician members of the Canadian Association of Emergency Physicians were invited to participate. Participants were presented with 20 organ donation scenarios that included poisoned and non-poisoned deaths, as well as one ideal scenario for organ or tissue donation used for comparison. Participants were unaware of the objective to explore donation in the context of poisoning deaths. Following the organ donation scenarios, a range of follow-up questions and demographics were included to explore factors influencing the decision to refer or not refer for organ or tissue donation. Results were reported descriptively and associations between physician characteristics and decisions to refer were assessed using odds ratios and 95% confidence intervals. Results: 208/2058 (10.1%) physicians participated. 25% did not refer in scenarios involving a drug overdose (n=71). Specific poisonings commonly triggering the decision to not refer included palliative care medications (n=34, 18%), acetaminophen (n=42, 22%), chemical exposure (n=48, 27%) and organophosphates (n=87, 48%). Factors associated with an increased likelihood to refer potential donors following overdose included previous organ and tissue donation training (OR=2.6), having referred in the past (OR=4.3), available donation support (OR=3.9), greater than 10 years of service (OR=2.1), large urban center (OR=3.8), holding emergency medicine certification (OR=3.6), male gender (OR=2.2, CI), and having indicated a desire to be a donor on government identification (OR=5.8). Conclusion: Scenarios involving drug overdoses were associated with under-referral for organ and tissue donation. As poisoning is not a contraindication for referral, this represents a potential source of donors. By examining characteristics that put clinicians at risk for under-referral of organ or tissue donors, becoming aware of potential biases, improving transplant knowledge bases, and implementing support and training programs for the organ and tissue donation processes, we have the opportunity to improve these rates and reduce morbidity and mortality for Canadians requiring organ or tissue donation.

Introduction: Aligning health systems appropriately to the needs of the elderly is an urgent global priority, according to the WHO. In Canada, ED length of stay has risen 16% for elderly patients in the last year. Agitation requiring chemical restraint is a common, high-risk problem for elderly in the ED. Improving outcomes in this heterogeneous population remain difficult due to inability to effectively identify and evaluate delirium, frailty, multi-morbidity, and incompatibility with the ED system. A data-driven approach to complex health problems is a recognized emerging tool for healthcare innovation. New opportunities for targeted quality improvement in the ED will be uncovered by identifying the clinical characteristics of elderly patients with agitation, and the system process factors that influence their outcomes. Methods: We studied 400 patients in a case-control study at two tertiary-care EDs over five years. Patients were randomly selected if age was greater than 75 years. 200 cases of patients who received an intravenous dose of haloperidol, midazolam and/or lorazepam were selected as a surrogate data marker for having agitation. Controls were randomly matched by age and ED diagnosis. Standardized clinical, systems and process variables were collected. We conducted a univariate analysis. Results: Elderly given intravenous medications for agitation had increased mortality (OR 3.8 CI: 1.6-10.7, p<0.001) and ED length of stay (27 vs. 15 hours, p<0.001). No statistical significance was found in clinical characteristics, CTAS scores, PRISMA7 frailty scores nor sentinel or return visits. There was no statistical difference in median hospital length of stay (8 vs. 6 days, p<0.70). No differences were found in median time from ED physician seeing a patient to first consultant request (73 vs. 83 mins, p=0.75). The largest time intervals contributing to ED length of stay were from first consultant request to hospital request (15 vs. 12 hours, p=0.056) and hospitalization delay (13 vs. 7 hours, p=0.45). Conclusion: Identification of high-risk elderly patients for targeted intervention through a data-driven approach is feasible and informative. Traditional clinical characteristics remain unhelpful in identifying and evaluating outcomes in elderly with agitation. We have identified a process factor that is clinically relevant and pragmatic to evaluate in our ED system. Future research focused on optimizing systems process factors to improve quality of elderly care should be prioritized.

Introduction: The optimal diagnostic strategy for children presenting to the Emergency Department (ED) with suspected appendicitis (SA), the most common non-traumatic surgical emergency in children, remains unclear. This study aims to identify which investigations and management priorities are preferred by Canadian surgeons prior to consultation from the ED. Methods: An internet survey was extended to practicing surgeons who are members of the Canadian Association of Pediatric Surgeons and Canadian Association of General Surgeons. Three case-based scenarios evaluated surgeons expected ED investigations and management for SA with varying severity of disease (simple - SA vs perforated - PA) and sex (male vs female). Differences across scenarios were determined by ANOVA and direct comparisons were reported using proportions and odds ratios with 95% confidence intervals. Results: Surveys were completed by 82 surgeons. Across the 3 cases, CBC (227/246, 92.3%) and urinalysis (188/246, 76.4%) were the sole investigations expected in >75% of responses. Expectations differed across cases for use of blood cultures (p<0.001), electrolytes (p<0.001), sexually transmitted infection testing (0.015) and ultrasound (US) (p<0.001). Blood cultures (26/82, 31.7% vs 4/82, 4.9%; OR 9.05 95%CI 2.88-37.33) and electrolytes (58/82, 70.7% vs 33/82, 40.2%; OR 3.59 95%CI 1.79-7.24) were expected more often in severe disease. US was expected more often in females (58/82,70.7% vs 25/82, 30.5%; OR 5.51, 95% CI 2.68-11.38). Expected management differed across cases for fluid boluses (p=0.01), intravenous (IV) analgesia (p<0.001) and antibiotics (p<0.001), with all differences attributed to severity of illness (fluids 73/82, 89.0% vs 59/82, 72.0% OR 3.16 95%CI 1.28-8.33; IV analgesia 66/82, 80.5% vs 42/82, 51.2% OR 3.93 95%CI 1.86-8.45; antibiotics 44/82, 53.7% vs 10/82, 12.2% OR 8.34 95%CI 3.59-20.44). Conclusion: Severity of illness and sex of the child impact the ED investigations and management expected by surgeons consulted for suspected appendicitis. Further research focusing on how these expectations influence patient outcomes should be conducted. Collaborative ED-surgery protocols for the diagnosis and management of acute appendicitis in children should be established.

Introduction: The emergency department (ED) is often the first point of access to the health care system for patients with an acute mental health crisis. Outpatient resources are limited, typically do not operate after hours, and patients and their families often lack sufficient information on where and how to access mental health services within their communities. The objective of this study was to determine which community healthcare resources patients attempted to access for their mental health condition prior to presenting to the ED. Methods: Between April 2016 to June 2017, a convenience sample of adult ( 18 years) patients presenting to an academic ED (annual census 65,000) with a mental health complaint were invited to complete a 23-item, paper-based survey. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 200 patients who completed the survey, mean (SD) age was 37 (16) years and 96 (48%) were male. 20 (10%) patients were brought to the ED involuntarily by police services. 175 (88%) had been previously diagnosed with a mental health condition, the most common being depression and/or anxiety (n=134, 67%). 47 (24%) patients indicated they were currently only connected to a primary care provider, while 94 (47%) patients indicated they had existing relationships with multiple mental healthcare providers. 117 (59%) patients attempted to see an alternative healthcare provider prior to coming to the ED. 78 (39%) patients had a pending scheduled appointment with a healthcare provider for their mental health condition, 44 (56%) of which were within 7 days of their ED visit, but chose to seek care in the ED. 38 (19%) patients either had a referral with no appointment date set, or had an impending mental health appointment scheduled more than 30 days from their ED visit. Conclusion: These findings suggest that most patients seeking ED care during a mental health crisis do so despite being connected to alternative healthcare providers and outpatient services. Future studies should attempt to determine reasons why patients with mental health conditions seek care in the ED, and examine barriers to mental health care in the community and outpatient setting.

Introduction: Despite revolutionary changes in the medical education landscape, journal club (JC) continues to be a ubiquitous pedagogical tool and is a primary way that residency programs review new evidence and teach evidence-based medicine. JC is a community of practice among physicians, which may help translate research findings into practice. Program representatives state that JC should have a goal of translating novel research into changes in clinical care, but there has been minimal evaluation of the success of JC in achieving this goal. Specifically, emergency medicine resident perspectives on the utility of JC remain unknown. Methods: We designed a multi-centre qualitative study for three distinct academic environments at the University of British Columbia (Vancouver, Victoria and Kelowna). Pilot testing was performed to generate preliminary themes and to finalize the interview script. An exploratory, semi-structured focus group was performed, followed by multiple one-on-one interviews using snowball sampling. Iterative thematic analysis directed data collection until thematic sufficiency was achieved. Analysis was conducted using a constructivist Grounded Theory method with communities of practice as a theoretical lens. Themes were compared to the existing literature to corroborate or challenge existing educational theory. Results: Pilot testing has revealed the following primary themes: (1) Only select residents are able to increase their participation in JC over the course of residency and navigate the transition from peripheral participant to core member; (2) These residents use their increased clinical experience to perceive relevance in JC topics, and; (3) Residents who remain peripheral participants identify a lack time to prepare for journal club and a lack of staff physician attendance as barriers to resident engagement. We will further develop these themes during the focus group and interview phases of our study. Conclusion: JC is a potentially valuable educational resource for residents. JC works as a community of practice only for a select group of residents, and many remain peripheral participants for the duration of their residency. Incorporation of Free Open-Access Medical Education resources may also decrease preparation time for residents and staff physicians and increase buy-in. To augment clinical impact, the JC community of practice may need to expand beyond emergency medicine and include other specialties.

Introduction: An emergency department visit may represent a sentinel event for someone who is older and frail, signalling a slide into dependence and functional decline. The gold standard for the treatment of frail older adults is a comprehensive geriatric assessment, involving consideration of multiple domains including mobility and function in activities of daily living. Despite this, when a chart audit was conducted in a Canadian metropolitan emergency department, none of the patients age 65 and older had a documented assessment of their function or mobility. In response, an occupational therapy program was implemented. The goals of this program were to reduce the number of unnecessary hospital admissions related to patient functional impairments, and to increase function, safety, and independence for patients upon discharge from the emergency department. Methods: The pilot project, which was completed in 2013, was evaluated using a mixed methods approach. Positive patient outcomes at that time included a reduction in avoidable admissions and better support for patients upon discharge from the emergency department. A survey of emergency department staff indicated that occupational therapy consultation added value to the diagnostic and discharge planning processes. However, due to changes in administrative priorities, several service redesigns were required. Multiple PDSA cycles were completed, and the development of a logic model guided and focused program development. Results: A reassessment of program objectives was conducted using 2015 data, which found that the number of patients seen by the occupational therapist remained the same, as did the percentage of patients discharged with support of occupational therapy intervention, such as provision of adaptive equipment or referral to community rehabilitation referrals. The percentage of patients discharged due to occupational therapy as a primary contributing factor rose slightly, and staff satisfaction with the program remained high. Conclusion: This evaluation proves that the provision of occupational therapy services in the emergency department is sustainable, benefits patients, and can be incorporated into the emergency department workflow and culture.

Introduction: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making many emergency medicine physicians have pursued specialized training to perform point of care biliary ultrasound in the emergency department (BUSED). The purpose of this study was to determine the usefulness of BUSED in predicting the need for surgical consultation and intervention for biliary disease. Methods: A retrospective study of 283 consecutive patients visiting the emergency department who received a BUSED scan from December 1, 2016 to July 16, 2017. Physician interpretations of the BUSED scans were collected from the electronic image storage and interpretation system. Additional data was collected from the electronic health record including lab values, the subsequent use of diagnostic imaging, and outcomes data including disposition, surgical consultation or intervention, and 28 day follow up for representation or complication. Descriptive statistics and logistic regression were performed. Results: Of the patients who received a biliary POCUS scan, 29% were referred to general surgery, and 43% of those referred proceeded to eventual cholecystectomy. Factors found to be independently predictive of surgical intervention on point of care BUSED scans included presence of gall stones (OR 13.01, 95%CI 5.02 to 27.1) and increased gallbladder wall thickness (OR 6.01, 95%CI 1.7 to 11.1). A total of 30% of patients receiving BUSED required at least one additional, radiology based imaging test (CT or diagnostic US). Average emergency department length of stay was substantially longer for those who required additional imaging as compared to those who were able to be diagnosed by BUSED alone (16.1 versus 5.2 hours, 10.9 hours 95%CI 10.6 11.2, p<0.05) . Conclusion: Point of care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gall stones and increased gall bladder wall thickness are highly predictive of the need for surgical intervention. Future, prospective studies are warranted to determine if point of care sonography is sufficient to proceed to surgery in select cases of uncomplicated biliary disease.

Introduction: Background: Studies in the US have demonstrated that many primary care staff and offices are inadequately prepared for paediatric emergencies. Although the Canadian Paediatric Society (CPS) recently reaffirmed their Guidelines for Paediatric Emergency Equipment and Supplies for a Physicians Office, no evaluation has been made regarding the impact of publishing these recommendations, or on the state of preparedness for paediatric emergencies in family physician offices. Objectives: The aim of this study was to evaluate awareness and adherence of family physicians in Ontario to the CPS guidelines on preparedness for paediatric emergencies. Methods: We conducted a province-wide, cross-sectional survey of 749 randomly selected family physicians. Participants were asked to complete a 14-question survey regarding clinic characteristics, incidence of paediatric emergencies, and preparedness of the clinic in the case of a paediatric emergency. Ethics approval was obtained from the regional Ethics Review Board. Results: 104 physicians responded to our Ontario survey (response rate of 14.8%). 71.2% of respondents reported seeing more than 10 children per week, and 58.7% and had experienced at least one paediatric emergency in the past year. The proportion of physicians reporting paediatric emergencies within the last year increased with the number of children seen - 37.9% of physicians who saw fewer than 10 children per week reported an emergency, compared to 85.7% of those who saw more than 40 children per week. 85.6% of respondents reported that they were unaware of the CPS guidelines on paediatric emergency preparedness. Only 9.6% of respondents were aware of the guidelines, and even fewer, 3.8% had read them. Of the physicians who were unaware of the guidelines, 4.5% [CI=0.2, -0.09] engaged in mock code sessions, 29.2% [CI=0.2, 0.2] were up-to-date on Paediatric Advanced Life Support (PALS), 1.1% [CI=0.03, -0.01] had written protocols outlining safe transport of children to hospitals, and 50.6% [CI=0.4, 0.6] stocked half or more of the recommended supplies. In comparison, of the physicians who were aware of the guidelines, 14.3% [CI=0.3, -0.04] engaged in mock code sessions, 35.7% [CI=0.1, 0.6] were up-to-date on PALS, 7.1% [CI=0.2, -0.06] had written protocols, and 78.6% [CI=0.8, 0.8] stocked half or more of the recommended supplies. Conclusion: A large proportion of respondents had experienced at least one paediatric emergency in the past year, but were overall underprepared. The majority of respondents, 85.6%, were not aware of the guidelines, compared to 9.6% who were aware of them. However, offices with the latter were more adherent to the guidelines recommendations. It will be important for CPS to consider how to further advocate for paediatric emergency preparedness in clinics that see children regularly.

Introduction: Asthma and/or chronic obstructive pulmonary disease (COPD) exacerbations often result in emergency department (ED) visits. This study examined the health-related personnel providing regular care to patients with asthma and/or COPD, as well as, explored the coordination of care between the ED and outpatient settings. Methods: Descriptive cross-sectional examination of patients presenting with asthma and/or COPD exacerbations to two EDs in Edmonton between August and December 2017. Using patient interview methods information on demographics, established health care connections and health system use was collected; information on consultations, disposition and referrals was collected through chart review methods. Results: A total of 50 patients were recruited (14 patients with asthma and 36 patients with COPD). Most of the patients with asthma were female (64%) and their median age was 36 years (interquartile range [IQR]: 29, 46); sex was evenly distributed among the patients with COPD and their median age was 68 years (IQR: 61, 78). The majority reported having a family doctor (86% of the patients with asthma and 94% of the patients with COPD). On the day of admission to the ED, 29% of the patients with asthma visited their family doctor while 42% of the patients with COPD visited their Respirologist; these doctors referred >70% of the patients to the ED. While in the ED, consultations were requested in 21% of the patients with asthma (all to Pulmonary) and in 78% of the patients with COPD (evenly divided between Medicine and Pulmonary). Transition coordinators and social workers were involved in the ED care of <15% of the patients with COPD. Most patients with asthma were discharged home (86%) and 64% of the patients with COPD were hospitalized. After discharge, 14% of the patients with asthma and 50% of the patients with COPD were referred to specialized care. Conclusion: While the study patients with asthma and COPD had different health professionals providing regular care to their respiratory conditions, they both sought care before presenting to the ED. More health professionals were involved in the ED care of patients with COPD than of those with asthma. This study provided important information to support further research projects exploring ways to effectively and efficiently improve the delivery, comprehensiveness and utilization of health care services.

Introduction: The use of personal mobile devices to record patient data appears to be increasing, but remains poorly studied. We sought to determine the magnitude and purposes for which Canadian emergency physicians (EPs) and residents use their personal mobile devices (PMDs) to record patient data in the emergency department (ED). Methods: An anonymous survey was distributed to EPs and residents in the Canadian Association of Emergency Physicians (CAEP) database between 27/02/17 and 23/03/17. The survey captured demographic information and information on frequency and purpose of PMD use in the ED, whether consent was obtained, how the information was secured, and any possible implications for patient care. Participants were also asked about knowledge of, and any perceived restrictions from, current regulations regarding the use of PMDs healthcare settings. Results: The survey response rate was 23.1%. Of 415 respondents, 9 surveys were rejected for incomplete demographic data, resulting in 406 participants. A third (31.5%, 128/406, 95% CI 27.0-36.3) reported using PMDs to record patient data. Most (78.1%) reported doing so more than once a month and 7.0% reported doing so once every shift. 10.9% of participants indicated they did not obtain written or verbal consent. Reasons cited by participants for using PMDs to record patient data included a belief that doing so improves care provided by consultants (36.7%), expedites patient care (31.3%), and improves medical education (32.8%). 53.2% of participants were unaware of current regulations and 19.7% reported feeling restricted by them. Subgroup analysis suggested an increased frequency of PMD use to record patient data among younger physicians and physicians in rural settings. Conclusion: This is the first known Canadian study on the use of PMDs to record patient data in the ED. Our results suggest that this practice is common, and arises from a belief that doing so enhances patient care through better communication, efficiency, and education. Our findings also suggest current practices result in risk of both privacy and confidentiality breaches, and thus support arguments for both physician education and regulation reform.

Introduction: In the third year of medical school, students participate in a four week period called Transition to Clerkship, followed by Shadow week, where students spend one week in the discipline prior to starting clerkship. In the past, students have identified that receiving specific additional training during Shadow week would help them succeed in their rotation. To address this problem, the curriculum discussed in this paper is being developed for third year students who will be commencing clerkship in Emergency Medicine (EM). Methods: In order to assess achievement of objectives within the curriculum, questionnaires were provided to participants in the morning and afternoon of the session, as well as at the end of their rotation. Evaluative analysis is done through the Kirkpatrick program evaluation framework based on descriptive comparison of scores on the questionnaires, followed by statistical analysis with the Mann-Whitney Test (2-tailed, p=0.05) and a reflective critique. Results: Learning activities in this curriculum included: case-based learning, video critique, role play, scavenger hunt, jigsaw activity, think-pair-share, and a game-show style game. This study aims to show if, and how, providing interactive, hands-on learning sessions, which are directly relevant to clinical practice in the emergency department, positively impacted medical students beginning their clerkship in EM. Conclusion: Learners showed statistically significant positive improvement on all learning objectives of the curriculum. A reflective critique provides insight into lessons learned from delivering this curriculum and future directions for this curriculum. This learner-centered curriculum with innovative teaching methods and a considerable number of active learning strategies has encouraged the learners to take responsibility for their own learning. While this curriculum took place in the medical school, it can apply equally to learners completing their EM clerkship in a community or tertiary Emergency Department.

Introduction: Pain management is a cornerstone of emergency department (ED) practice, yet ongoing pain after ED discharge and return visits for inadequate analgesia are common. Over-the-counter (OTC) acetaminophen and nonsteroidal anti-inflammatory drugs are widely accepted first line agents for mild to moderate pain. Previous research has not investigated how patients actually consume such agents after discharge, and if they consume them synergistically and at sufficient doses for optimal analgesia. We sought to determine the proportion of patients in ongoing pain post-discharge that were utilizing analgesics as well as the type and dose of agent(s) used. Methods: Adults presenting to our ED with an acutely painful musculoskeletal complaint during research assistant hours were eligible for enrollment. After excluding non-English speakers as well as admitted, pregnant/breastfeeding, and chronic pain patients, consenting subjects completed in-person questionnaires during their ED stay and a follow-up telephone interview 2-3 days later. Results: 158 individuals were approached during the study period, of which 99 enrolled. 78 completed follow-up. At follow-up, 71 (91%) individuals experienced ongoing pain with a median score of 5 (interquartile range (IQR) 3-6) on an 11-point scale. 48 (67%) of patients still in pain consumed analgesics in the preceding 24 hours. The most commonly used agents were acetaminophen by 18 individuals (38% of analgesic users), ibuprofen by 16 (33%), and naproxen by 9 (19%). 29 respondents (60% of analgesic users) were using solely oral OTC analgesics. Only 15 (31% of analgesic users) used multiple agents concurrently, and 11 (23%) used prescription opioids. Acetaminophen was used at a median daily dose of 1500mg (IQR 1000-2000mg), much lower than that recommended for maximal analgesia (4000mg). Ibuprofen daily doses (1200mg, IQR 800-1300mg) were slightly lower than typical recommended doses (1600mg, 400mg every 6 hours). Conclusion: Only two-thirds of patients with ongoing pain at 2-3 days post-ED discharge were consuming analgesics, most commonly acetaminophen and ibuprofen. Of patients using analgesics, less than one-third used multiple agents. OTC medications are not used by most patients at doses for maximal analgesia. It may be possible to reduce pain burden and repeat-visits in discharged ED patients by optimizing the use of OTC analgesics.

Introduction: The importance of early recognition and treatment of Sepsis has been emphasized over the last several years. In an attempt to better prioritize these patients, the Canadian Triage and Acuity Scale (CTAS) revised the adult temperature modifier after 2008 to define fever as 38.0C or higher and apply SIRS criteria, appearance and immunocompromise to assign a CTAS level of 2, 3, or 4. Prior to 2008, the fever threshold was defined as 38.5C and SIRS criteria were not included. This study looks to see if these changes increased the sensitivity of the temperature modifier. Methods: This study is a retrospective cohort analysis of patients presenting with a temperature of <36.0C or >38.0C to six Edmonton-area EDs in calendar years 2008 (n=26181) and 2012 (n=51622). Outcomes of interest included the temperature modifier predicted score and the actual assigned CTAS score. Data was extracted from the HASS/iSoft EDIS database including: presenting complaint, vital signs, CTAS score, and applied CTAS modifier to generate a before and after comparison of the actual and theoretical impact of temperature modifier revisions on the CTAS score, for both time periods. Results: Applying the pre-2008 temperature modifier to the 2008 patient cohort assigned 11.5% to CTAS 2, 39.8% to CTAS 3, and 33.3% to CTAS 4. Applying the post-2008 revised temperature modifier assigned 22.2% CTAS 2, 41.9% CTAS 3, and 27.6% CTAS 4. Carrying out the same analysis on the 2012 patients pre- results were 12.4% CTAS 2, 46.4% CTAS 3, 30.2% CTAS 4; and the post results were 21% CTAS 2, 47.7% CTAS 3, and 25% CTAS 4. Differences between pre- and post-results were statistically significant (p<0.0001) in both years. The actual triage scores in 2012 were 18.7% CTAS 2 indicating the temperature modifier was not always correctly applied and 50.6% CTAS 3 as other modifiers were sometimes applied. Conclusion: There was a significant increase in sensitivity following the post 2008 revisions to the CTAS temperature modifier when applied to two large ED patient cohorts. The differences between theoretical and actual CTAS scores was less dramatic as nurses were able to apply other first order or special modifiers to assign an appropriate score. Further analysis will be carried out to determine the impact of the temperature modifier revisions on time to antibiotic and admission rates.