Introduction: Studies suggest that there is a significant discrepancy between emergency physicians diagnosis of TIA and confirmation by neurologists. The objectives of our study were to identify factors associated with neurologists confirmation of TIA in patients referred from the emergency department. Methods: Data were obtained from a prospective cohort study across more than 8 university-affiliated Canadian hospitals from 2006-2017 of adult patients diagnosed with a TIA or non-disabling stroke in the ED. Patients presenting after 1 week of symptom onset, receiving TPA as part of a stroke code, with a GCS<15 at baseline, and without a neurology assessment within 90 days were excluded. Univariate analyses were performed with t-tests or chi-square tests as indicated. Multivariate analysis with backward elimination was performed to identify unique predictors of TIA confirmation. Results: Of 8,669 patients diagnosed with TIA in the ED, 7,836 (90%) were assessed by neurology. The mean age of patients was 68.2 years and 71.1% presented with their first ever TIA. The rate of confirmation of TIA by neurology was 56%. The most common alternate diagnoses included migraines (26%), peripheral vertigo (10%), syncope (6%), and seizure (4%). The 3 strongest predictors of confirmation of TIA were infarct on imaging (OR 2.31, 2.03-2.63), history of weakness (OR 2.19, 1.95-2.48), and history of language disturbance (OR 2.05, 1.79-2.34). The 3 strongest predictors of an alternate diagnosis were syncope (OR 0.51, 0.39-0.67), history of bilateral weakness (or 0.51, 0.31-0.84), and confusion (OR 0.57, 0.48-0.67). Conclusion: The rate of TIA confirmation by neurology in our study was 56%. Emergency physicians should have a high index of suspicion of TIA in patients with history of weakness and language disturbance, and should resist referring to a stroke prevention clinic, patients with syncope, bilateral findings, or confusion.

Introduction: Health advocacy training is an important part of emergency medicine practice and education. There is little agreement, however, about how advocacy should be taught and evaluated in the postgraduate context, and there is no consolidated evidence-base to guide the design and implementation of post-graduate health advocacy curricula. This literature review aims to identify existing models used for teaching and evaluating advocacy training, and to integrate these findings with current best-practices in medical education to develop practical, generalizable recommendations for those involved in the design of postgraduate advocacy training programs. Methods: Ovid MEDLINE and PubMed searches combined both MeSH and non-MeSH variations on advocacy and internship and residency. Forward snowballing that incorporated grey literature searches from accreditation agencies, residency websites and reports were included. Articles were excluded if unrelated to advocacy and postgraduate medical education. Results: 507 articles were identified in the search. A total of 108 peer reviewed articles and 38 grey literature resources were included in the final analysis. Results show that many regulatory bodies and residency programs integrate advocacy training into their mission statements and curricula, but they are not prescriptive about training methods or assessment strategies. Barriers to advocacy training were identified, most notably confusion about the definition of the advocate role and a lower value placed on advocacy by trainees and educators. Common training methods included didactic modules, standardized patient encounters, and clinical exposure to vulnerable populations. Longitudinal exposure was less common but appeared the most promising, often linked to scholarly or policy objectives. Conclusion: This review indicates that postgraduate medical education advocacy curricula are largely designed in an ad-hoc fashion with little consistency across programs even within a given discipline. Longitudinal curriculum design appears to engage residents and allows for achievement of stated outcomes. Residency program directors from emergency medicine and other specialties may benefit from promising models in pediatrics, and a shared portal with access to advocacy curricula and the opportunity to exchange ideas related to curriculum design and implementation.

Introduction: Direct observation is essential to assess medical trainees and provide them with feedback to support their progression from novice to competent physicians. However, learners consistently report infrequent observations, and calls to increase direct observation in medical training abound. In this study, a theory-driven approach using the Theoretical Domains Framework (TDF) was applied to systematically investigate factors that serve as barriers and enablers to direct observation in residency training. Methods: Semi-structured interviews of faculty and residents from various specialties at two large tertiary-care teaching hospitals were conducted. An interview guide based on the TDF was used to capture 14 theoretical domains that may influence direct observation. Interview transcripts were independently coded using direct content analysis by two researchers, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on the frequencies of beliefs reported, presence of conflicting beliefs, and perceived influence on direct observation practices. Results: Data saturation was achieved after 12 resident and 13 faculty interviews, with a total of 10 different specialties represented. Median postgraduate year among residents was 4 (range 1-6), and mean years of independent practice among faculty was 10.3 (SD=8.6). Ten TDF domains were identified as influencing direct observation: knowledge, skills, beliefs about consequences, social professional role and identity, intention, goals, memory/attention/decision-making, environmental context and resources, social influences, and behavioural regulation. Discord between faculty and resident intentions to engage in direct observation, coupled with the social expectation that residents should be responsible for ensuring observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as an important and pervasive theme. Conclusion: This study identified key barriers and enablers to direct observation. The influencing factors identified in this study provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training.

Introduction: Survival from cardiac arrest has been linked to the quality of resuscitation care. Unfortunately, healthcare providers frequently underperform in these critical scenarios, with a well-documented deterioration in skills weeks to months following advanced life support courses. Improving initial training and preventing decay in knowledge and skills are a priority in resuscitation education. The spacing effect has repeatedly been shown to have an impact on learning and retention. Despite its potential advantages, the spacing effect has seldom been applied to organized education training or complex motor skill learning where it has the potential to make a significant impact. The purpose of this study was to determine if a resuscitation course taught in a spaced format compared to the usual massed instruction results in improved retention of procedural skills. Methods: EMS providers (Paramedics and Emergency Medical Technicians (EMT)) were block randomized to receive a Pediatric Advanced Life Support (PALS) course in either a spaced format (four 210-minute weekly sessions) or a massed format (two sequential 7-hour days). Blinded observers used expert-developed 4-point global rating scales to assess video recordings of each learner performing various resuscitation skills before, after and 3-months following course completion. Primary outcomes were performance on infant bag-valve-mask ventilation (BVMV), intraosseous (IO) insertion, infant intubation, infant and adult chest compressions. Results: Forty-eight of 50 participants completed the study protocol (26 spaced and 22 massed). There was no significant difference between the two groups on testing before and immediately after the course. 3-months following course completion participants in the spaced cohort scored higher overall for BVMV (2.2 ± 0.13 versus 1.8 ± 0.14, p=0.012) without statistically significant difference in scores for IO insertion (3.0 ± 0.13 versus 2.7± 0.13, p= 0.052), intubation (2.7± 0.13 versus 2.5 ± 0.14, p=0.249), infant compressions (2.5± 0.28 versus 2.5± 0.31, p=0.831) and adult compressions (2.3± 0.24 versus 2.2± 0.26, p=0.728) Conclusion: Procedural skills taught in a spaced format result in at least as good learning as the traditional massed format; more complex skills taught in a spaced format may result in better long term retention when compared to traditional massed training as there was a clear difference in BVMV and trend toward a difference in IO insertion.

Introduction: In high stakes, performance-oriented professions, the ability to execute in stressful situations is both a prerequisite and an intense focus of training. Stress Inoculation Training (SIT) is a three-step cognitive-behavioural intervention aimed at reducing stress that may play a role in helping EM teams prepare for high acuity events. We conducted a systematic review of literature in medicine and performance-oriented professions to inform the development of an EM-focused SIT curriculum. Methods: An electronic search of Ovid MEDLINE, Web of Science Core Collection, PsychINFO, ProQuest and Scopus was conducted. Inclusion criteria were studies investigating the impact of stress inoculation training on performance and anxiety reduction. Data extraction included recording of performance and anxiety domains measured in each study and the details of how the stress inoculation training was delivered. Screening of articles, data extraction, and summarization were conducted by two independent reviewers using a standardized data extraction tool. Results: Our search yielded 431 studies; 40 were screened for full-text review and 10 met inclusion criteria. A total of 930 trainees throughout the 10 studies were enrolled. Four studies consisted of students in varying disciplines, including law, technology, education, and general undergraduate students, and 4 studies were composed of military personnel. No papers directly examined the effect of stress inoculation training on performance in healthcare. A change in performance and a reduction in anxiety and/or stress was noted in 90% of studies. Training length, experience of trainer, or group size did not appear to impact outcomes. Notably, heart rate variability (HRV) did not appear to be affected throughout the studies included, while cortisol and subjective stress were consistently reduced. Conclusion: SIT is an effective tool for enhancing performance and reducing stress and anxiety in high intensity environments. Studies examining the effect of EM-focused SIT on individual, team and patient-orient outcomes are needed.

Introduction: Enhanced skills training in emergency medicine (EM) for family physicians (CCFP(EM)) has existed since the 1970s. Accreditation standards define what every program must and should have, yet little is known on what is currently done across Canada. Our objectives were to: 1) describe major components of CCFP(EM) programs; and 2) determine how programs incorporate these components into their curriculum. Methods: A rigorous development process included expert content development and in-person pilot testing using Royal College Emergency Medicine Program Directors. An electronic survey questionnaire comprised of 63 questions was administered to all 17 CCFP(EM) program directors using a modified Dillman technique. Non-responders were sent a reminder email every 2 weeks over a 6-week period and an in-person reminder was given to non-responders at a face to face meeting 4 weeks after the initial survey was sent in June 2016. Results: All 17/17 (100%) program directors responded. There was considerable variation in administrative structure and financial support for each program. All programs provided ultrasound courses for basic skills (trauma, abdominal aortic aneurysm, intrauterine pregnancy). Variation exists for offering independent ultrasound certification (77%), advanced scanning (18%) and protected academic time for scanning (53%). All programs utilize high fidelity simulation. Some programs use in situ simulation (18%) and hold a simulation boot camp (41%). Most centres required an academic project, most commonly a quality assurance project (53%) and/or a critical appraisal of the literature (59%). Publication or national conference presentations were required by 12% of programs. Competency based assessments use simulation (88%) and direct observations (53%). Only 24% of programs have a transition to practice curriculum. All programs maintain strong connections to family medicine. Conclusion: This study demonstrates diverse structures of CCFP(EM) programs across Canada. Programs are similar regarding the provision of ultrasound, simulation and protected teaching time. Variation exists in administrative structure and financial resources of each program, academic project requirements, and how programs perform competency based assessments.

Introduction: Pediatric musculoskeletal (MSK) image interpretation has been identified as a knowledge gap among emergency medicine trainees. The main objective of this study was to implement a validated on-line pediatric MSK radiograph interpretation system with a performance-based competency endpoint into pediatric emergency fellowship programs and examine the number of cases needed to achieve a competency threshold of 80% accuracy, sensitivity and specificity. We further determined proportion who successfully achieved competency in a given module and the change in accuracy from baseline to competency. Methods: This was a prospective cohort multi-centre study. There were seven MSK radiograph modules, each containing 200-400 cases (demo-https://imagesim.com/course-information/demo/). Thirty-seven pediatric emergency medicine fellows participated for 12 months. Participants did cases until they reached competency, defined as at least 80% accuracy, sensitivity and specificity. We calculated the overall and per module median number of cases required to achieve competency, proportion of participants who achieved competency, median time on case, and the mean change in accuracy from baseline to competency. Results: Overall, the median number of cases required to achieve competency was 76 (min 54, max 756). Between different body parts, there was a significant difference in the median number of cases needed to achieve competency, p <0.0001, with ankle and knee being among the most challenging modules. Proportions of those who started a module and completed it to competency varied significantly, and ranged from 32.4% in the ankle module to 97.1% in the forearm/hand, p<0.0001. The overall median time on each case was 34.1 (min 7.6, max 89.5) seconds. The overall change in accuracy from baseline to 80% competency was 13.5% (95% CI 12.1, 14.8), with the respective Cohens effect size of 1.98. The change in accuracy was different between modules, p=0.001, with post-hoc analyses demonstrating that the ankle/foot radiograph module had a greater increase in accuracy relative to elbow (p=0.009) and pelvis/femur (p=0.006). Conclusion: It was feasible for pediatric emergency medicine fellows to complete each learning pediatric MSK learning module to competency within approximately one hour, with the exception of the ankle module. Learners who completed the modules to competency demonstrated very significant increases in interpretation skill.

Introduction: Emergency medicine (EM) is a demanding specialty with high rates of physician burnout. As emergency physicians, we must stay healthy to promote healthy living, optimize our ability to care for our patients, extend our careers, and be there for our families. While we all desire a healthy lifestyle, maintaining one in practice can be difficult. We sought to investigate the strategies emergency physician employ to maintain and improve health and wellness while mitigating the professions stressors. Methods: From April 2015 to July 2017, forty-three wellness champions from Canada, the USA, and Australia were identified using a snowball sampling technique. Each participant answered 5 introductory questions and 8 productivity questions pertaining to health and wellness. These were transcribed and loaded to a publicly accessible blog, ALiEM.com, as part of the Healthy in EM series. Two investigators reviewed the transcripts using inductive methods and a grounded theory approach to generate themes and subthemes using coding software, NVivo (Burlington, Massachusetts), until saturation was achieved. Consensus between investigators (JC, ZP) established the master code and audit trail. An external audit by investigators (TC, BT) not involved with the initial analysis was performed to ensure reliability. Results: Major themes including diet, sleep, exercise and social activities were coded and further subcategorized along with perspectives, habits, personal philosophies, and career diversity. These themes translated across both professional and personal aspects of participants lives. For example, the pre-shift and post-shift strategies often included some form of regimented activities-of-daily-living that required discipline to adhere to at work and home. Conclusion: Our findings show the importance of homeostasis in the professional and personal realm among expert emergency medicine physicians. Among healthy emergency physicians, diet, sleep, and exercise patterns intertwined with perspectives, habits, personal philosophies, and social activities contributed to maintenance of wellness.

Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.

Introduction: Simulation-based education systems have increased physician skill in radiograph interpretation. However, the degree of skill retention and the factors that influence it are relatively unknown. The main objective of this research was to determine the rate and quantity of skill decay in post-graduate trainee physicians who completed a simulation-based learning intervention of radiograph interpretation. The impact of testing and refresher education on skill decay was also examined. Methods: This was a prospective, multicenter, analysis-blinded, four arm randomized control trial conducted from November 2014 to June 2016. Study interventions were administered using an on-line learning and measurement platform. Pediatric and emergency medicine residents in the United States and Canada were eligible for study participation. Participants were randomized to one of four groups. All participants completed an 80-case deliberately practiced learning set of pediatric elbow radiographs followed by an immediate 20-case post-test. Following this, Group 1 had no testing until 12 months; Groups 2, 3, and 4 had testing (20 cases without feedback) every 2 months until 12 months, but Group 3 also had refresher education (20 cases with feedback) at six months while Group 4 had refresher education at two, six, and ten months. The main outcome measure was accuracy at 12 months, adjusted for immediate post-test score, days to completion of 12 month test, and time on case. Based on prior data, we assumed the smallest important difference between groups in learning decay is 10%, a between-participant/within-group standard deviation of 17%, a type I error probability of 5%, a power of 80% and adjusted for three tests with a Bonferroni correction. For the primary analysis of Group 1 versus 2, 3, 4, this resulted in a minimal total sample size of 56, with 14 participants per group. Results: We enrolled 106 participants that completed all study interventions. The sample sizes in Groups 1, 2, 3, and 4 were 42, 22, 22, and 20 respectively. Overall, accuracy increased by 11.8% (95% CI 9.8, 13.8) with the 80-case learning set and then decreased by 5.5% (95% CI 2.5, 8.5) at 12 months. The difference in learning decay in Group 1 vs. Groups 2, 3, 4 was -8.1% (95% CI 2.5, 13.5), p=0.005. For Group 2 vs. Group 3 and 4, it was +0.8% (95% CI -7.2, 7.3), p=0.8, and between Group 3 vs. Group 4 it was +0.8% (95% CI -7.3, 10.1), p=0.8. Conclusion: Skill decay was significantly reduced by testing with 20 cases every two months. Refresher education had no additional effect to testing on reducing learning decay.

Introduction: Head injury is a common presentation to all emergency departments. Previous research has shown that such injuries may be complicated by delayed intracranial hemorrhage (D-ICH) after the initial scan is negative. Exposure to anticoagulant or anti-platelet medications (ACAP) may be a risk factor for D-ICH. We have conducted a systematic review and meta-analysis to determine the incidence of delayed traumatic intracranial hemorrhage in patients taking anticoagulants, anti-platelets or both. Methods: The literature search was conducted in March 2017 with an update in April 2017. Keyword and MeSH terms were used to search OVID Medline, Embase and the Cochrane database as well as grey literature sources. All cohort and experimental studies were eligible for selection. Inclusion criteria included pre-injury exposure to oral anticoagulant and / or anti-platelet medication and a negative initial CT scan of the brain (CT1). The primary outcome was delayed intracranial hemorrhage present on repeat CT scan (CT2) within 48 hours of the presentation. Only patients who were rescanned or observed minimally were included. Clinically significant D-ICH were those that required neurosurgery, caused death or necessitated a change in management strategy, such as admission. Results: Fifteen primary studies were ultimately identified, comprising a total of 3801 patients. Of this number, 2111 had a control CT scan. 39 cases of D-ICH were identified, with the incidence of D-ICH calculated to be 1.31% (95% CI [0.56, 2.27]). No more than 12 of these patients had a clinically significant D-ICH representing 0.09% (95% CI [0.00, 0.31]). 10 of them were on warfarin and two on aspirin. There were three deaths recorded and three patients needed neurosurgery. Conclusion: The relatively low incidence suggests that repeat CT should not be mandatory for patients without ICH on first CT. This is further supported by the negligibly low rate of clinically significant D-ICH. Evidence-based assessments should be utilised to indicate the appropriate discharge plan, with further research required to guide the balance between clinical observation and repeat CT.

Introduction: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. To-date, study of sex-based concussion differences in general adult populations have been limited. This study examined sex-based differences in concussion outcomes. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score 13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls at 30 and 90 days post ED discharge captured extent of PCS using the Rivermead Post-Concussion questionnaire (RPQ), effect on daily living activities measured by the Rivermead Head Injury Questionnaire (RHIQ), and overall health-related quality of life using the 12-item Short Form Health Survey (SF-12). Dichotomous and categorical variables were compared using Fishers exact test; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Results: Overall, 130/250 enrolled patients were female. The median age was 35 years; men trended towards being younger (median=32 years; IQR: 23, 45) than women (median=40 years; IQR: 22, 52). Compared to women, more men were single (56% vs 38% (p=0.007) and employed (82% vs 71% (p=0.055). Men and women experienced different injury mechanisms (p=0.007) with more women reporting injury due to a fall (44% vs 26%), while more men were injured at work (16% vs 7%) or due to an assault (11% vs. 3%). Men had a higher return to ED rate (13% vs. 5%; p=0.015). Women had higher RPQ scores at baseline (p<0.001) and 30-day follow-up (p=0.001); this difference was not significant by 90 days (p=0.099). While women reported on the RHIQ at 30 days that their injury affected their usual activities significantly more than men (Median=5, IQR: 0, 11 vs. median=0.5, IQR: 0.5, 7; p=0.004), both groups had similar scores on the SF-12 physical composite and mental composite scales at all three measurement points. Conclusion: In a general ED concussion population, demographic differences exist between men and women. Based on self-reported and objective outcomes, womens usual activities may be more affected by concussion and PCS than men. Further analysis of these differences is required in order to identify different treatment options and ensure adequate care and treatment of injury.

Introduction: The proportion of Canadians receiving anticoagulation medication is increasing. Falls in the elderly are the most common cause of minor head injury and an increasing proportion of these patients are prescribed anticoagulation. Emergency department (ED) guidelines advise performing a CT head scan for all anticoagulated head injured patients, but the risk of intracranial hemorrhage (ICH) after a minor head injury (patients who have a Glasgow comma score (GSC) of 15) is unclear. We conducted a systematic review and meta-analysis to determine the point incidence of ICH in anticoagulated ED patients presenting with a minor head injury. Methods: We systematically searched Pubmed, EMBASE, Cochrane database, DARE, google scholar and conference abstracts (May 2017). Experts were contacted. Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE) guidelines were followed with two authors reviewing titles, four authors reviewing full text and four authors performing data extraction. We included all prospective studies recruiting consecutive anticoagulated ED patients presenting with a head injury. We obtained additional data from the authors of the included studies on the subset of GCS 15 patients. We performed a meta-analysis to estimate the point incidence of ICH among patients with a GCS score of 15 using a random effects model. Results: A total of five studies (and 4,080 GCS 15, anticoagulated patients) from the Netherlands, Italy, France, USA and UK were included in the analysis. One study contributed 2,871 patients. Direct oral anticoagulants were prescribed in only 60 (1.5%) patients. There was significant heterogeneity between studies with regards to mechanism of injury, CT scanning and follow up method (I2 =93%). The random effects pooled incidence of ICH was 8.9% (95% CI 5.0-13.8%). Conclusion: We found little data to reflect contemporary anticoagulant prescribing practice. Around 9% of warfarinized patients with a minor head injury develop ICH. Future studies should evaluate the safety of selective CT head scanning in this population.

Introduction: Despite widespread use of FAST in trauma, there is a lack of data supporting its usefulness. We sought to identify the impact of FAST on clinical management of blunt trauma patients. Methods: This health records review was conducted at a single large academic Level 1 trauma center emergency department. Patients with a suspicion of acute blunt traumatic abdominal injury were identified from our health records database. Data were collected regarding FAST utilization, CT scan utilization and timing, need for definitive management, disposition, and length of stay (LOS). Results: 285 patients were included, 152 (53.3%) received a FAST examination, with 33 (22%) having a direct impact on clinical management. CT was performed in 112 (73.6%) of the FAST group, with mean time to imaging of 147.4 minutes, time to trauma team assessment of 21.5 minutes, and ED-LOS of 8.6 hours. In the non-FAST group, 33 (24.8%) received a CT, with time to imaging of 133 minutes, time to trauma team assessment of 133 minutes, and ED-LOS of 13.8 hours. 75.6% of the FAST group required admission and 9.2% required definitive management; admission was needed for 38.3% of the non-FAST group and 2.2% required definitive management. Conclusion: This is the first study to assess patient outcomes with respect to FAST in the era of early whole body CT in trauma. Although FAST does not directly impact care for the majority of blunt trauma patients, it demonstrates usefulness in some patients by directing CT utilization and expediting disposition from the ED.

Introduction: Achieving just outcomes in sexual assault cases is one of the most serious and complex problems facing the health care and justice systems. The objectives of this analysis were to determine the prevalence and correlates of Sexual Assault Evidence Kit (SAEK) completion and release to police among sexual assault cases presenting at the hospital emergency department. Methods: Data for this cross-sectional study come from the Sexual Assault and Partner Abuse Care Program (SAPACP) case registry (Jan1-Dec31, 2015) at The Ottawa Hospital, a unique medical-forensic access point and the only facility offering SAEK collection in Ottawa. Bivariable and multivariable logistic regression models were conducted using odds ratios (OR), adjusted ORs, and 95% confidence intervals (CI). Results: In 2015 406 patients were seen by the SAPACP and 202 (77.10%) were eligible for a SAEK. Among eligible cases, 129 (63.86%) completed a SAEK and only 60 (29.70%) released the SAEK to police for investigation. Youth cases below 24 years of age (AOR:2.23, 95% CI: 1.18-4.23) and presenting within 24h (AOR:0.93-3.40) were the strongest independent factors contributing to SAEK completion. Cases who were uncertain of the assailant (AOR:3.62, 95% CI:1.23-10.67) and assaults that occurred outdoors (AOR:3.14, 95% CI:1.08-9.09) were the cases most likely to release the SAEK to police. Conclusion: Our study has shown high attrition levels along the continuum of care and justice for sexual assault case. Even with access to specialized forensic evidence collection, many do not complete a SAEK and even fewer release the evidence to police for legal investigation.

Introduction: Necrotizing soft tissue infection (NSTI), a potentially life-threatening diagnosis, is often not immediately recognized by clinicians. Delays in diagnosis are associated with increased morbidity and mortality. We sought to summarize and compare the accuracy of physical exam, imaging, and Laboratory Risk Indicator of Necrotizing Fasciitis (LRINEC) Score used to confirm suspected NSTI in adult patients with skin and soft tissue infections. Methods: We searched Medline, Embase and 4 other databases from inception through November 2017. We included only English studies (randomized controlled trials, cohort and case-control studies) that reported the diagnostic accuracy of testing or LRINEC Score. Outcome was NSTI confirmed by surgery or histopathology. Two reviewers independently screened studies and extracted data. We assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 criteria. Diagnostic accuracy summary estimates were obtained from the Hierarchical Summary Receiver Operating Characteristic model. Results: We included 21 studies (n=6,044) in the meta-analysis. Of physical exam signs, pooled sensitivity and specificity for fever (49.4% [95% CI: 41.4-57.5], 78.0% [95% CI: 52.2-92.0]), hemorrhagic bullae (30.8% [95% CI: 16.2-50.6], 94.2% [95% CI: 82.9-98.2]) and hypotension (20.8% [95% CI: 7.7-45.2], 97.9% [95% CI: 89.1-99.6]) were generated. Computed tomography (CT) had 88.5% [95% CI: 55.5-97.9] sensitivity and 93.3% [95% CI: 80.8-97.9] specificity, while plain radiography had 48.9% [95% CI: 24.9-73.4] sensitivity and 94.0% [95% CI: 63.8-99.3] specificity. Finally, LRINEC 6 (traditional threshold) had 67.5% [95% CI: 48.3-82.3] sensitivity and 86.7% [95% CI: 77.6-92.5] specificity, while a LRINEC 8 had 94.9% [95% CI: 89.4-97.6] specificity but 40.8% [95% CI: 28.6-54.2] sensitivity. Conclusion: The absence of any one physical exam feature (e.g. fever or hypotension) is not sufficient to rule-out NSTI. CT is superior to plain radiography. The LRINEC Score had poor sensitivity, suggesting that a low score is not sufficient to rule-out NSTI. For patients with suspected NSTI, further evaluation is warranted. While no single test is sensitive, patients with high-risk features should receive early surgical consultation for definitive diagnosis and management.

Introduction: Sepsis remains a major cause of mortality. In the Emergency Department (ED), rapid identification and management of sepsis have been associated with improved outcomes. Following ED assessment, patients with infection may be directly admitted to the Intensive Care Unit (ICU), or alternatively admitted to hospital wards or sent home, with risk of future deterioration necessitating ICU admission. Little is known regarding outcomes and costs of ICU sepsis patients who are initially admitted to a ward or discharged home (delayed ICU admission), as compared to those with direct ICU admission from the ED. Methods: We analyzed a prospectively collected registry (2011-2014) of patients admitted to the ICU with a diagnosis of sepsis at two academic hospitals. We included all adult patients with an index ED visit within 72 hours of ICU admission. Patients were categorized into 3 groups: 1) Admitted directly to ICU; 2) Admitted to wards, with ICU admission within 72 hours; and 3) Sent home, with ICU admission within 72 hours. ICU length of stay (LOS) and total costs (both direct and indirect) were recorded. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model, controlling for confounding variables (including patient sex, comorbidities, and illness severity). Results: 657 ICU patients were included. Of these, 338 (51.4%) were admitted directly from ED to ICU, 246 (37.4%) were initially admitted to the wards, and 73 (11.1%) were initially sent home. In-hospital mortality was lowest amongst patients admitted directly to the ICU (29.5%), as compared to patients admitted to ICU from wards (42.7%), or home (61.6%). Delayed ICU admission was associated with increased odds of mortality (adjusted odds ratio 1.85 [1.24-2.76], P<0.01) and increased median ICU LOS (11 days vs. 4 days, P<0.001). Median total costs were lowest among patients directly admitted to the ICU ($19,924, [Interquartile range [IQR], 10,333-32,387]), as compared to those admitted from wards ($72,155 [IQR, $42,771-122,749]) and those initially sent home ($45,121 [IQR, $19,930-86,843]). Conclusion: Only half of ED sepsis patients ultimately requiring ICU admission within 72 hours of ED arrival are directly admitted to the ICU. Delayed ICU admission is associated with higher mortality, LOS, and costs.

Introduction: Current guideline recommendations for optimal management of non-purulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is currently a lack of evidence to guide emergency physicians on when to select oral versus intravenous antibiotic therapy. The primary objective was to identify risk factors associated with oral antibiotic treatment failure. A secondary objective was to describe the epidemiology of adult emergency department (ED) patients with non-purulent SSTIs. Methods: We performed a health records review of adults (age 18 years) with non-purulent SSTIs treated at two tertiary care EDs. Patients were excluded if they had a purulent infection or infected ulcers without surrounding cellulitis. Treatment failure was defined any of the following after a minimum of 48 hours of oral therapy: (i) hospitalization for SSTI; (ii) change in class of oral antibiotic owing to infection progression; or (iii) change to intravenous therapy owing to infection progression. Multivariable logistic regression was used to identify predictors independently associated with the primary outcome of oral antibiotic treatment failure after a minimum of 48 hours of oral therapy. Results: We enrolled 500 patients (mean age 64 years, 279 male (55.8%) and 126 (25.2%) with diabetes) and the hospital admission rate was 29.6%. The majority of patients (70.8%) received at least one intravenous antibiotic dose in the ED. Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR]=6.31, 95% CI=1.80 to 22.08), chronic ulcers (OR=4.90, 95% CI=1.68 to 14.27), history of MRSA colonization or infection (OR=4.83, 95% CI=1.51 to 15.44), and cellulitis in the past 12 months (OR=2.23, 95% CI=1.01 to 4.96) were independently associated with oral antibiotic treatment failure. Conclusion: This is the first study to evaluate potential predictors of oral antibiotic treatment failure for non-purulent SSTIs in the ED. We observed a high rate of treatment failure and hospitalization. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for non-purulent SSTIs being managed as outpatients.

Introduction: Skin and soft tissue infections (SSTIs) are a common reason for presentation to an emergency department (ED). Although many patients with mild SSTI are managed with oral antibiotics, those with mild-moderate infections are often treated with parenteral antibiotics, managed in EDs as outpatients using once daily intravenous cefazolin combined with oral probenecid. The purpose of our study was to determine if cephalexin 500 mg orally four times daily was non-inferior to cefazolin 2 g intravenously daily plus probenecid 1 g orally daily in the management of uncomplicated mild-moderate SSTIs patients presenting to the ED.. Methods: This was a prospective, multi-center, double dummy-blind, randomized controlled non-inferiority trial conducted at two tertiary care teaching hospitals in Canada. Patients were enrolled if they presented to the ED with an uncomplicated SSTI, in a 1:1 fashion to oral cephalexin or intravenous cefazolin plus oral probenecid for up to 7 days. The primary outcome was failure of therapy at 72 hours. Clinical cure at 7 days, intravenous to oral step-down, admission to hospital and adverse events were also evaluated. Results: 206 patients were randomized with 104 patients in the cephalexin group and 102 in the cefazolin and probenecid group. The proportion of patients failing therapy at 72 hours was similar between the treatment groups (4.2% and 6.1%, risk difference 1.9%, 95% CI (-3.3% to 7.1%), p-value for non-inferiority=0.001). Clinical cure at seven days was not significantly different (100% and 97.7%, risk difference -2.3%, 95% CI (-4.9% to 0.3%), p-value for non-inferiority=0.008). Conclusion: Cephalexin at appropriate doses appears to be a safe and effective alternative to outpatient parenteral cefazolin and probenecid in the treatment of uncomplicated mild to moderate SSTIs who present to the ED.

Introduction: The Canadian Syncope Risk Score (CSRS) was developed to identify patients at risk for serious adverse events (SAE) within 30 days of an Emergency Department (ED) visit for syncope. We sought to validate the score in a new cohort of ED patients. Methods: We conducted a multicenter prospective cohort study at 8 large academic tertiary-care EDs across Canada from March 2014 to Dec 2016. We enrolled adults (age 16 years) who presented within 24 hours of syncope, after excluding those with persistent altered mentation, witnessed seizure, intoxication, and major trauma requiring hospitalization. Treating ED physicians collected the nine CSRS predictors at the index visit. Adjudicated SAE included death, arrhythmias and non-arrhythmic SAE (myocardial infarction, serious structural heart disease, pulmonary embolism, severe hemorrhage and procedural interventions within 30-days). We assessed area under the Receiver Operating Characteristic (ROC) curve, score calibration, and the classification performance for the various risk categories. Results: Of the 2547 patients enrolled, 146 (5.7%) were lost to follow-up and 111 (4.3%) had serious condition during the index ED visit and were excluded. Among the 2290 analyzed, 79 patients (3.4%; 0.4% death, 1.4% arrhythmia) suffered 30-day serious outcomes after ED disposition. The accuracy of the CSRS remained high with area under the ROC curve at 0.87 (95%CI 0.82-0.92), similar to the derivation phase (0.87; 95%CI 0.84-0.89). The score showed excellent calibration at the prespecified risk strata. For the very-low risk category (0.3% SAE of which 0.2% were arrhythmia and no deaths) the sensitivity was 97.5% and negative predictive value was 99.7% (95%CI 98.7-99.9). For the very high-risk category (61.5% SAE of which 26.9% were arrhythmia and 11.5% death) the specificity was 99.4% and positive predictive value was 61.5% (95% CI 43.0-77.2). Conclusion: In this multicenter validation study, the CSRS accurately risk stratified ED patients with syncope for short-term serious outcomes after ED disposition. The score should aid in minimizing investigation and observation of very-low risk patients, and prioritization of inpatient vs outpatient investigations or following of the rest. The CSRS is ready for implementation studies examining ED management decisions, patient safety and health care resource utilization.