Introduction: La b-card (Boussignac Cardiac Arrest Resuscitation Device) est un dispositif permettant d'assurer une oxygénation passive continue lors des manoeuvres de compressions/décompressions réalisées dans le cadre d'un arrêt cardiaque. Ce dispositif fonctionne par création d'une valve virtuelle induite par l'accélération d'un débit d'oxygéne via des micro-canalicules. Cette valve est censée s'opposer aux flux de gaz entrant et sortant de la cage thoracique lors des compressions/décompressions. Elle permettrait d'obtenir une pression positive intra thoracique lors des compressions, et une pression intra thoracique négative lors des décompressions. L'expérimentation conduite a pour but de mesurer la pression statique créée dans le dispositif par le débit d'oxygène, ainsi que les valeurs de pressions et de flux générés en intra thoracique. Methods: La b-card est almimentée par un débit d'oxygène de 15 L/min, et connectée via différentes interfaces à un poumon test pourvu de capteurs:

-Capteur de pression des voies aériennes (PAW en cm H2O).

-Capteur de débit au niveau des voies aériennes.

-Capteur de pression “intra thoracique” (PIT max et min; et Pression Expiratoire Intra Thoracique).

Les mesures sonrt effectuées sans b-card, puis avec b-card connectée à un masque facial, un masque laryngé, une sonde trachéale.

Results: La pression “statique”, celle de la valve virtuelle, mesurée au niveau de la b-card reste stable à 6 cm d'H2O, sous un débit de 15 L/min. Elle permet une résistance à hauteur de cette valeur aux flux de gaz entrant ou sortant du thorax expérimental en fonction des compressions/décompressions. Les pressions intra thoraciques positives mesurées lors des compressions restent équivalentes autour de 25 à 30 cm H2O, et ce quelle que soit l'interface utilisée. Les pressions intra thoraciques négatives mesurées lors des décompressions restent équivalentes autour de 10 à 15 cm d'H2O, et ce quelle que soit l'interface utilisée. Conclusion: Les pressions intra thoraciques obtenues en associant une oxygénation passive par la b-card à des compressions/décompressions continues permettent d'assurer une ventilation efficace et synchrone. Les pressions mesurées au niveau du dispositif sont constamment inférieures à la pression d'ouverture moyenne oesophagienne, ce qui éviterait toute insufflation gastrique.

Introduction: Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, such as external aortic compression which has been identified as an immediately applicable maneuver to address the leading cause of battlefield mortality: junctional hemorrhage. However, it is currently unclear how to optimize this technique. Methods: This prospective, block-randomized, cross-over simulation study of compression optimization was performed on a model of central vessel compression that recorded weight (lbs) and pressure (mmHg). Forty participants simulated external aortic compression on the ground as well as a stretcher with and without a backboard. Participants were blinded to compression weight and pressure, as well as the purpose of the study, to minimize preparation bias. Manoeuvres were performed in alternating order to control for skill acquisition and fatigue. Scripted instructions were followed to compress with 1 then 2 hands, and to apply “sustainable effort” and then “maximal effort”. Results: The greater the compressor's bodyweight the greater their mean compression (Pearson’s correlation 0.9342). Using one-hand, a mean of 28% participant bodyweight (95%CI, 26% - 30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased rescuer bodyweight transmission by 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p<0.001). Adding a backboard increased transmission of rescuer bodyweight 7%-15% (p<0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4%-9% (p < 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p <0.001). Conclusion: Efficacy is maximized with larger-mass, two hands, and compression on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). This study demonstrates the feasibility of indirect pressure as a potential temporizing measure for life-threatening haemorrhage not amenable to direct compression.

Introduction: In certain circumstances, skin and soft tissue infections are managed with intravenous (IV) antibiotics. In our center, patients initiated on outpatient IV antibiotics are followed up by a home parental therapy program the following day. A significant number of these patients require a repeat visit to the ED because of clinic hours. Probenecid is a drug that can prolong the half-life of certain antibiotics (such as cefazolin) and can therefore avoid a repeat ED visit, reducing health care costs and improve ED capacity. Our goal was to increase probenecid usage in the ED in order to optimize management of skin and soft tissue infections (SSTI) in the ED. The primary outcome was to compare the usage of probenecid in the pre and post-intervention phase. Secondary outcomes were to compare revisit rates between patients receiving cefazolin alone vs cefazolin + probenecid. Methods: Using administrative data merged with Computerized Physician Order Entry (CPOE), we extracted data 90 days pre- and 90 post-intervention (February 11, 2015 to August 11, 2015). The setting for the study is an urban center (4 adult ED’s with an annual census of over 320,000 visits per year). Our CPOE system is fully integrated into the ED patient care. The multi-faceted intervention involved modifying all relevant SSTI order sets in the CPOE system to link any cefazolin order with an order for probenecid. Physicians and nurses were provided with a 1 page summary of probenecid (indications, contra-indications, pharmacology), as well as decision support with the CPOE. Any patients who were receiving outpatient cefazolin therapy were included in the study. Results: Our analysis included 2512 patients (1148 and 1364 patients in the pre/post phases) who received cefazolin in the ED and were discharged during the 180 day period. Baseline variables (gender, age, % admitted) and ED visits were similar in both phases. In the pre-intervention phase 30.2% of patients received probenecid and in the post-intervention phase 43.0%, for a net increase of 12.8% (p=<0.0001). Patients who received probenecid had a 2.2% (11.4% vs 13.6%, p=0.014) lower re-visit rate in the following 72H. Conclusion: We have implemented a CPOE based clinical decision support intervention that demonstrated significant increase in probenecid usage by emergency physician and resulted in a decrease in ED revisits. This intervention would result in health care cost-savings.

Introduction: Fever is one of the most common reasons for presentation to the emergency department (ED). Interestingly, a number of small studies suggest that fever may function as a modulator of the QT interval in healthy individuals and an arrhythmogenic trigger in patients with occult congenital QT abnormalities. The objective of this study was to explore whether presence of fever adversely affects the QT interval, and whether medications known to prolong this interval affect any association found. Methods: We performed a retrospective, single center study identifying patients (age > 18 years) presenting to the ED with fever (temperature > 38.0 °C) between January 1st, 2012 and December 31st, 2013 via electronic chart review. The subset for analysis were those who had an ECG both at time of fever and while afebrile (within 30 days of initial ECG). Temperature measurement was within 30 minutes of ECG. Actively paced patients were excluded. Univariate and multiple regression analysis were used to determine risk factors for QT derangement in patients with fever. Results: 2018 febrile visits occurred during the reviewed period, 181 of these patients went on to be included in the study. 54.1% of study subjects were female, and the average age was 68.9 years old. The etiology of fever was predominately infectious (69.6%), with community acquired pneumonia being the most frequent cause (24.3%). We found the median corrected QT interval to be significantly shorter in febrile as compared to afebrile patients [QTc = 388.7ms, (371.5-407.5) vs 406.7, (386.7-434.4); p < 0.001]. This difference was observed in both sexes. Males were found to be more likely to experience medication induced QTc prolongation [OR 5.35, 95% CI = 1.46 - 19.68; P < 0.05]. Two instances of Torsades de pointes were identified in our study, both occurring in males on QT prolonging medications. Conclusion: In an ED patient population, fever generally shortens the QT interval independent of sex. Prolongation of the QT interval during fever should thus increase clinical suspicion of congenital or acquired QT disorders. Additionally, males appear to be more susceptible to medication-induced derangements in the QT interval and may require more vigilant monitoring when treated with multiple QT prolonging medications.

Introduction: Paramedics often attend seizure patients in the pre-hospital setting. Received wisdom is that hypoglycemia is frequently present during a seizure or is a ‘cause’ of seizures. Recent literature disputes this. The purpose of this study was to determine the frequency of hypoglycemia in patients identified as having “seizure” listed as the primary or final problem code in Ambulance Call Reports from a large regional paramedic base hospital program. Methods: Retrospective analysis of a database of ambulance call reports (ACRs) from January 01-December 31, 2014. All 2854 ACRs with paramedic determined primary or final problem codes of “seizure” were identified from a database of all calls performed by 8 municipal paramedic services covering a total urban and rural population of 1.4 million. Municipal paramedic services used iMedic electronic ACRs. A 10% sample generated by a random number table was analyzed. ACRs were manually searched and data extracted onto spreadsheets. Results were described using frequencies and summary statistics. Results: A total of 285 call were analyzed. 207 (72.6%) calls were adults and 78 (27.4%) were paediatric (age <18). Seizures were witnessed by paramedics in 23/285 (8.1%) calls; adults 17/207 (8.2%), paediatric 6/78 (7.7%). A blood sugar was determined in 237/285 (83.2%) of all calls; adults 182/207 (87.9%), paediatric 55/78 (70.5%). In calls were paramedics witnessed a seizure a blood sugar was determined 17/21 (80.9%) of the time; adults 13/17 (76.5%), paediatric 6/6 (100%) Hypoglycemia (BS < 4.0 mm/L) was found in only 1 case - 1/237 (0.4%); adults 0/ 207 (0%), paediatric 1/78 (1.3%). The child was age 1, had a GCS 13, and the blood sugar was 3.9 mm/L. Conclusion: Hypoglycemia was rarely found in patients who had a seizure and were attended to by paramedics in the pre-hospital setting. The routine determination of blood sugars in all patients who have had a seizure prior to paramedic arrival should be reconsidered.

Introduction: Paramedics frequently attend out-of-hospital seizure patients. They administer oxygen, check blood glucose levels and if within scope of practice, start IVs and administer benzodiazepines. Little is know about how frequently these procedures are performed. The objective of this study was to determine the frequency of procedures performed by paramedics (Advanced Care (ACP), Primary Care IV (PCP-IV) and Primary Care non-IV (PCP)) attending seizure patients in a regional paramedic base hospital program. Methods: Retrospective analysis of a secondary database of ambulance call reports (ACRs) (January 01-December 31, 2014). All 2854 ACRs with paramedic determined primary / final problem codes of “seizure” were identified from total calls performed by 8 municipal paramedic services (MPSs), covering an urban and rural population of 1.4 million. MPSs used iMedic electronic ACRs. A 10% sample, generated using a random number table, was analyzed. ACRs were manually searched and data extracted onto spreadsheets. Findings were summarized using descriptive statistics. Results: 285 calls were analyzed; (adult 72.7%, paediatric (age <18) 27.3%). Paramedics witnessed seizures in 8.1% of all calls they attended; (paediatric 7.8%). The blood sugar was checked in 87.9% of adult calls; (ACP 88.7%, PCP-IV 89%, PCP 77.8%) and in 70.5% of paediatric calls; (ACP 72.0%, PCP-IV 63.3%, PCP 70.5%). Oxygen was administered in 80.7% of adult calls; (ACP 85.9%, PCP-IV 78.0%, PCP 80.7%) and 83.3% of paediatric calls; (ACP 92.0%, PCP-IV 80.1%, PCP 82.4%). IVs were started by paramedics (if in scope of practice) in 28.0% of adult calls; (ACP 47.9%, PCP-IV 16.1%) and 6.6% of paediatric calls; (ACP 8.0%, PCP-IV 5.6%) Midazolam was administered in 10.4% of ACP attended calls and in 91.0% of the calls were they witnessed seizures. Transport occurred in 93.2% of adult calls and 100% of paediatric calls. Conclusion: ACPs were more likely to perform procedures on seizure patients than PCPs or PC-IVs. Children were much less likely to have procedures performed on them - blood sugar checks, and IV starts - but more likely receive oxygen and be transported. These findings have training implications.

Introduction: Thoracic trauma is, depending on severity, a frequent cause of mortality, morbidity, hospitalization and incapacity. Minor closed thoracic injuries are often discharged from Emergency Departments (ED) and treated on an outpatient basis. One potential complication is the development of a delayed hemothorax (DHx). Currently, there exists no consensus on the best method for classifying DHx. The goal of this study is to evaluate the level of interrater and intrarater agreement with respect to three classification schemes for DHx. Methods: This was a secondary analysis drawn from a prospective multicenter cohort study of consecutive patients presenting to one of four Canadian ED for minor closed thoracic trauma over a four-year period. Using intraclass correlation (ICC), chest radiographs of 50 patients previously diagnosed with new DHx within 2 weeks of discharge were randomly selected and subjected to analysis by emergency physicians, radiologists, surgeons and family physicians using three different methods of classification to study their reliability, both between raters and for the same rater on two separate evaluations, at determining hemothorax severity. Results: Analysis of ICC values demonstrates poor interrater agreement (Global ICC 0.44, 0.35-0.52) for the current classification method, based on professional experience and opinion. The second method, based on hemothorax / total thorax ratio calculation, showed good Global ICC (0.58, 0.49-0.67) on lateral films. The third method, based on presence / absence of overflow from the costo-phrenic angle, showed equally good Global ICC (0.56, 0.47-0.64) on postero-anterior films and was more homogenous across the four different groups of physicians. Conclusion: Our results demonstrate that the current method used to classify DHx, based on gestalt, shows poor interrater agreement. Two innovative classification methods achieved good interrater agreement. Future studies, analyzing possible correlation of this more reliable classification method to objective, clinical measures would be of value to management decisions.

Introduction: Previous investigations of the diagnostic accuracy of point-of-care ultrasound (POCUS) in distal radius fractures (DRF) report a wide range of sensitivities (71%-98%) and specificities (73%-100%) when performed by medical professionals, which may reflect inconsistencies in POCUS training or sonographer experience. The purpose of this study was to determine the accuracy of POCUS performed by pre-clerkship medical students with minimal POCUS training compared to standard radiography in diagnosing DRF in adult patients with traumatic wrist injuries, in order to assess POCUS as an alternative to traditional radiographic imaging. Methods: This prospective observational study was conducted from June to September 2015. The study population consisted of adults presenting to the emergency department (ED) with distal forearm pain secondary to traumatic injury within the past seven days and for whom radiographic imaging was ordered. Patients were evaluated using POCUS performed by medical students with no prior experience who had received one hour of POCUS training taught by an emergency ultrasound fellowship-trained ED physician. A pre-test probability of fracture was stratified as low or high and documented independently by the treating physician. Students were blinded to pre-test probability and radiography results. Results: Of the 52 patients enrolled, 18 had DRF diagnosed by radiographic imaging. Compared to radiography, student-performed POCUS had 72% overall sensitivity (95% CI, 47%-90%) and 85% specificity (95% CI, 69%-95%), with 81% overall accuracy. In the high pre-test probability group (N = 20), POCUS had 80% sensitivity (95% CI, 52%-96%) and 60% specificity (95% CI, 15%-95%). In the low pre-test probability group (N = 32), POCUS had 33% sensitivity (95% CI, 1%-91%) and 90% specificity (95% CI, 73%-98%). Conclusion: POCUS performed by medical students demonstrated reasonable success in diagnosing DRF, with overall sensitivity and specificity in keeping with published data. Within the low pre-test probability group, the diagnostic accuracy of POCUS suggests that ultrasound was an unreliable alternative to radiographic imaging for DRF in this cohort. Future analysis of the factors leading to DRF missed by POCUS as being related to adequacy of POCUS training, image capture, or sonographer experience will further explore the utility of POCUS as a diagnostic alternative.

Introduction: Decreasing patient Length of Stay (LOS) in the Emergency Department (ED) improves patient safety. Numerous studies have taken differing approaches to supplementing care at triage in order to decrease LOS, however, have not proven to be financially sustainable. The goal of this study was to explore financially viable options to expedite care in a safe way and reduce patient LOS. Methods: The ED process chain was identified. Two reviewers observed triage for a 4-hour period following patients. Times from patient arrival to: completion of triage, completion of registration, test ordering, physician assessment and final disposition were measured. Results were presented at departmental rounds. Nursing staff, Physician Assistants, Residents and Physician staff were paired in interdisciplinary groups to brainstorm and trial approaches to expedited test ordering and use of technology to carry out orders. Results: Triage interruptions increased time to triage a patient up to 3 times baseline, and 33% of triage interactions were interrupted. A bottleneck occurred at registration, increasing time to be registered by up to 30 minutes. Also, registration is using antiquated technology, significantly increasing registration time. Average patient LOS was 249 min, but was only 120 min if there was no delay in test ordering for patients. Average time for MD disposition was 129 min, but was only 47 minutes if there was no delay in ordering tests. Brainstorming lead to the following ideas: 1) use of companion phones to access already-working ED MD for test ordering and ECG interpretation 2) the use of the computer system to flag new orders or ECG for triage patients 3) use of a dedicated iPad in zones 4) increased standing orders for RNs to order diagnostic imaging. Conclusion: Patient LOS was reduced by lack of delay in test ordering, in keeping with previous studies. Numerous points in the process chain were identified for creating an economically sustainable supplemented triage to improve patient flow. These were: interruptions to triage, registration bottleneck, technology at registration, test ordering at triage. Ways in which to effectively order tests at triage include: MD-companion phones, pre-existing computer program, dedicated iPad in zones. The next step in this study is to trial each of these low-cost technologies.

Introduction / Innovation Concept: Musculoskeletal medicine (MSKM) complaints account for a significant portion of emergency room visits. Furthermore, MSKM diagnostic and management skills are poorly taught in undergraduate medicine and emergency medicine (EM). Here, we successfully developed an MSKM curriculum resulting in objectively improved resident acumen. Methods: Curriculum development was achieved by surveying local EM residents on their perceived MSKM deficits, and effective MSK teaching strategies. A literature search was also completed identifying MSKM teaching shortcomings. Finally, orthopaedic surgeons were asked which clinical entities they thought should be emphasized in our curriculum. Curriculum, Tool, or Material: A case-based MSKM curriculum was created. Cases emphasized commonly occurring emergency department presentations, topics that EM practitioners self-identified as requiring further teaching, commonly missed problems at first presentation, and high-risk cases if mismanaged. Curriculum implementation consisted of three, half-day, workshops. Workshops included didactic lectures, MSKM physical exam practice, and MSKM cases. MSKM cases required resident history taking and physical exam practice, radiography interpretation, and management plan formulation. Objective assessments of resident MSKM knowledge and skill were given to the learners before and after the workshops. Survey questions were grouped into 3 categories: MSK assessment, investigation, and management. Questions were scored on a 5-point Likert scale, ranging from “not at all confident” to “very confident”. A Wilcoxon Signed Rank Test indicated statistically significant improvement in learner confidence within all three domains after the first workshop (n=19 learners; assessment: p<0.001, investigation: p<0.001, management: p<0.001), and after the second workshop (n=24 learners; assessment: p<0.001, investigation: p<0.001, management: p<0.001). Conclusion: We successfully incorporated MSKM teaching into our academic curriculum based on previously identified weaknesses, resulting in improved resident MSKM case management. Further MSKM teaching sessions and evaluations to facilitate knowledge and skill maintenance are currently under development.

Introduction: Head injury is a major cause of bicycling-related disability and death, and more likely to occur in unhelmeted riders. Legislation regarding helmet use varies by province. In Ontario, helmet use is not mandatory for cyclists >= age 18, and approximately 50 % of adult cyclists do not routinely wear helmets. Non-legislative approaches to increase helmet use have included education, public health campaigns, and helmet giveaways, but sustained effect is typically limited. The goal of the HEADSTRONG Behaviour Study is to identify injured adult cyclists who do not regularly wear helmets, and effect sustained helmet use. The strategy incorporates evidence-based elements of health behaviour change, including: reducing barriers, education and modelling, providing necessary materials, and social support. Methods: Prospective cohort study in downtown Toronto teaching hospital, launched Nov 2015. ED clinician (EP or NP) will recruit injured cyclists (consecutive, convenience sample) who report not regularly wearing a helmet nor owning a suitable one. Study endpoint: 100 enrolled (to estimate prevalence of usage of +/- 10%, alpha 0.05, power >90%, assuming 80% study completion and 50 % helmet wearing at 12 months). Exclusion criteria: unable to consent, admitted to hospital, age <18. Each element of the HEADSTRONG Behaviour Strategy is intended to facilitate patient adoption and maintenance of the desired behaviour, including: 1) enrolment/education by research associate while still in the ED; 2) provision and fitting of a free bicycle helmet; 3) social contract commitment and tailored reminders to document ongoing helmet use: participant agrees to respond to brief electronic survey follow-ups at two weeks, two months, six months, and twelve months; 4) social media engagement with participation in the HEADSTRONG Twitter group, which engages other enrolees and cycling advocacy groups; 5) peer nomination: the participant who is complying with the social contract is encouraged to nominate an uninjured non helmet-wearing colleague to enrol in the study. Results: Primary outcomes include: recruitment rate, enrolment, and sustained participation through follow-up period. Secondary outcomes include age, gender and social demographics of helmet recipients, and participation of peers. Conclusion: Discussion of strategy and interim results at six month interval will be presented at CAEP.

Introduction: There is very little data about pediatric palliative care (PPC) patients’ visits to the emergency department (ED). This study’s goal was to determine the characteristics of PPC patients who consult the ED. Methods: A five-year retrospective chart review, conducted at a tertiary care pediatric university-affiliated hospital. Eligible patients initially consulted with the PPC team between April 1st 2007 and March 31st 2012. For each eligible patient, ED visits between these dates were included, using the ED’s electronic data system. Data about each visit was drawn from the electronic data system and the patient’s medical chart. This study was IRB approved. Results: During the study period, 290 new patients were followed by the PPC team; of these, 94 (32.4%) consulted the ED at least once (total of 219 visits). The median number of visits per patient was 2 (range: 1-8). Patient median age was 7 years 5 months (range: 1 month-22 years) and most common baseline diagnoses were: oncological diagnosis (39.4%), encephalopathy (27.7%) or genetic/chromosomal anomaly (13.8%). No patients died in the ED, but 36 (38.3%) died during the episode of care following one of their ED visits and 18 (19.1%) of them died within 72h of admission. PPC patients presented to the ED 219 times acutely ill: 11.4% of visits were triaged CTAS (Canadian Triage and Acuity Scale) level 1, 39.3% CTAS 2, 39.3% CTAS 3 and 10% CTAS 4 or 5. Many patients (37.9%) arrived by ambulance, 24.2% were admitted to the resuscitation room. Most patients consulted during day (45.2%) or evening (41.1%) shifts. Median length of stay was 3h50min (range: 13min - 15h10min). Reasons for consultation were respiratory distress/dyspnea (30.6%), pain (12.8%), seizure (11.4%), fever (9.1%), gastrointestinal symptoms (8.2%), fatigue (7.3%) and technical issues with catheters (5.9%). Most (79%) patients had investigations in the ED; 61.2% were admitted to wards, 7.3% to the PICU, and 20.5% were discharged. Two-thirds of patients (65.7%) had previously signed an advanced care directive at the time of their ED visit; discussions about goals of care were present in 37.4% of medical charts. Conclusion: Most PPC patients presented to the ED acutely ill, requiring work-up and admission. One-third presented in their end of life. Understanding the characteristics of PPC patients who consult the ED is the first step in offering better care for these complex patients.

Introduction / Innovation Concept: Acute care skills are difficult to teach but can be improved using high-fidelity simulation training. We developed a comprehensive acute care “Nightmares-FM” simulation course (NM) for our Family Medicine residents and compared it to our standard simulation teaching- episodic Acute Care Rounds (ACR). Methods: NM course consisted of an initial 2 day session followed by 3 follow-on sessions interspersed throughout the PGY-1 year. ACR participants got access to 3 sessions interspersed throughout the PGY-1 year, each focusing on a different aspect of acute care. Both groups got access to the NM manual which covered the relevant topics: shock, arrhythmias, shortness of breath, altered level of consciousness and myocardial infarction. The manual is physiology-based and written specifically at the level that an average Family Medicine resident would be expected to perform at during on-call crises or emergency medicine rotations. 12 residents participating in the NM and 12 residents in time-matched ACR filled out questionnaires asking them to rate their level of knowledge of various aspects of acute care. Self-reported changes before and after each session, and at the end of the year, were analyzed using Wilcoxon matched pairs test. End of the year mean scores were compared using a two sided t-test. Finally, we developed a high-complexity acute care Objective Structured Clinical Examination (OSCE): COPD exacerbation with septic shock requiring use of positive pressure ventilation, fluids and vasopressors. The groups participated in the OSCE in February of their PGY-2 year and were graded using a validated scoring sheet marked by two independent expert video reviewers. Curriculum, Tool, or Material: NM initial 2-day session significantly improved the resident’s self-assessment scores on all 20 items of the questionnaire (p<0.05). Time matched ACR improved 11 out of 20 items (p<0.05) level. Follow-up NM sessions improved 5-8 out of 20 items, (p<0.05). Follow-up ACR sessions improved 1-5 out of 20 items, (p<0.05). End of the year means were higher for 13/20 items in the NM group (p>0.05) The NM group scored significantly higher on both the mean scores of OSCE individual categories: Initial assessment, Diagnostic workup, Therapeutic interventions and Communication and teamwork (p<0.05) and the Global Assessment Score (p<0.026). Conclusion: “Nightmares-FM” course is more effective than our standard curriculum at teaching acute care skills to Family Medicine residents.

Introduction: Delirium is a frequent complication among seniors in the emergency department (ED). This condition is often underdiagnosed by ED professionals even though it is associated with functional & cognitive decline, longer hospital length of stay, institutionalization and death. Frailty is increasingly recognized as an independent predictor of adverse events in seniors and screening for frailty in EDs has recently been recommended. The aim of this study was to assess if screening seniors for frailty in EDs could help identify those at risk of ED-induced delirium. Methods: This study is part of the Incidence and Impact measurement of Delirium Induced by ED-Stay study, an ongoing multicenter prospective cohort study in 5 Quebec EDs. Patients were recruited after 8 hours in the ED exposure & followed up to 24h after ward admission. Frailty was assessed at ED admission using the Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) which classified seniors from robust (1/7) to severely frail (7/7). Seniors with CSHA-CFS ≥ 5/7 were considered frail. Delirium was assessed using the Confusion assessment method and Delirium Index. Results: Of the 380 patients recruited, mean age was 76.5 (±8.9). Male were 50%. Mean stay in the ED was 1.4 day (±0.82). Preliminary data show an incidence of ED-induced delirium of 8.4%. Average frailty score at baseline was 3.5/7. 72 patients were considered frail, while 289 were considered robust. Among the frail seniors, there were 48.4% (30-66%) patients with ED-induced delirium vs 17.9% (13.7-22.0] in the non-frail ones (p<0.0001). Conclusion: Increased frailty appears to be associated with increased ED-induced delirium. Screening for frailty at emergency triage could help ED professionals identify seniors at higher risk of ED-induced delirium. Further studies are required to confirm the importance of the association between frailty and ED-induced delirium

Introduction: Frailty is a state of vulnerability, and may go unrecognized in emergency medical services (EMS). Identifying frailty earlier may allow for services to be offered proactively to maintain function and prevent further health deterioration. The Clinical Frailty Scale (CFS) can be used to screen for frailty, but has only been validated when used by physicians. Our objective was to evaluate the feasibility and validity of a Care Partner-completed CFS, facilitated by a paramedic or nurse. Methods: A prospective sample of older adults (age ≥ 70 years) presenting in two settings (to EMS, following a 911 call, and to Geriatric Ambulatory Care) between February 2009 and March 2010 were included. Care partners completed a survey that included the nine-point CFS, which grades from 1 (very fit) to 9 (terminally ill). Demographic, clinical and outcome data were collected from the health care record, with one year follow-up. Based on clinical evaluations a frailty index was calculated for each patient. In each setting, descriptive statistics were used to compare fitter patients (CFS scores <5) to frailer ones (CFS scores >4). Results: The mean age was 82.2 ± 5.9 years (n=198) and most were women (n = 118, 62.1%). The Care Partner-CFS was incomplete for 3 surveys. The median CFS score in both the clinic and EMS groups was 5 (interquartile range = 4-6). The Care Partner-CFS correlated moderately with their independently assessed frailty index (0.64; p<0.01; n=195). Most patients (n=125; 64%) had frailty scores > 4. Frail patients were older and had worse health outcomes than the patients with score <5. More EMS patients were severely frail or very severely frail compared to the geriatric clinic patients (n = 19, 19% vs. n =5, 5%). Conclusion: The Care Partner-CFS is a feasible and valid method for evaluating frailty in the EMS and medical clinic settings where frailty was common. It may be a useful EMS screening tool to identify those that could benefit from comprehensive assessment and follow-up after emergency care. Future research will evaluate this approach in multiple populations with community based follow-up intervention for those at higher risk.

Introduction: ED patient comorbidity is difficult to ascertain for research. Traditional surrogates such as triage acuity, admission rate, and age have been used to approximate patient complexity. Differences between EDs for the management of similar conditions are nevertheless difficult to reconcile. The Charlson Comorbidity Index (CCI) contains 19 categories and is a validated predictor of the ten-year mortality for a patient who may have a range of comorbid conditions. CCI is based on the International Classification of Diseases (ICD) diagnosis codes found in administrative data such as the Discharge Abstract Database (DAD). The DAD collects this, and other inpatient information, for all Canadian hospitals. We sought to develop a linkage between the regional ED database and the regional inpatient DAD in order to derive a CCI score for each ED patient as a surrogate of comorbidity. Methods: We used regional data from Vancouver Coastal Health (VCH) over a 2.5 year period from April 2013 - September 2015. An algorithm was created to identify CCI conditions in the regional DAD. Whenever a patient visited the ED a query was made to the DAD going back for 5 years to acquire CCI relevant diagnoses and enter these diagnoses as well as the CCI weighting into the ED database. Patient DAD records from VCH were utilized no matter in which ED a patient presented. No information from admissions outside the region was available. Results: There were 931,596 regional ED visits made by 446,579 unique patients in a total of 11 EDs (6 urban and 5 rural). In total there were 127,233 patients with a CCI score (13.7% of total visits). The average CCI was 0.40 (SD 1.31) with a range of 0.12 at the urban urgent care centre to 0.52 at the urban tertiary care centre. More isolated rural EDs tended to have higher percentages of patients with CCI scores than community urban EDs. Higher acuity, age, and ambulance arrival, ED death, all correlated to higher CCI scores. The most common CCI conditions were “diabetes with complications” (10/11 EDs) and was present in 35,816 (3.8%) visits and “cancer” (10/11 EDs) present in 34,624 (3.7%) ahead of COPD (26,451 visits) and CHF (25,233 visits). Conclusion: Use of the CCI is a novel way to passively capture patient comorbidities without reliance on a data entry technician. Limitations include the inability to link to hospitalization data outside a specific health region.

Introduction: In 2006, Alberta implemented an Electronic Health Record called the Alberta Netcare Portal (ANP). The ANP provides provincial read-only access to lab tests, diagnostic imaging, medication information and numerous text reports. There is no computerized order entry, and care is coordinated using a hybrid of paper charting and various electronic systems. Here, we quantify observed ANP use by physician participants providing care in four urban Emergency Departments (EDs) in Alberta. The results form part of a larger mixed methods research project aimed at detecting broader implications of ANP use for patient care. Methods: Between October 2014 and July 2015, ED physicians at four EDs (University of Alberta Hospital [UAH], Grey Nuns Community Hospital [GNCH], Foothills Medical Centre [FMC], Peter Lougheed Centre [PLC]) participated in structured clinical observations. Observations were purposively sampled during the first hours of shifts, when physicians orient themselves to the patients they will see during the rest of their shift, including reviewing available historic patient information. Observers used a tablet based tool to generate a time-stamped record of the information tools used alongside patient care. Information tools included permanent paper records, paper excluding permanent documentation, the ANP, clinical and other applications accessed via desktop computers, and mobile devices. Observers also recorded contextual data, including participant commentary, on paper field notes. Results: Across the 4 sites, 142 physicians participated in 376 sessions for a total of 566 observed physician-hours. Participants accessed information in different computerized applications and on paper (i.e., a ‘hybrid’ care environment). The highest proportion of observed physician time interacting with ANP was observed at the UAH (7.0%-8.1%, all values 95% Confidence Intervals). Physicians spent less time using ANP at GNCH (4.1%-4.8%), which was similar to the Calgary EDs (FMC: 4.4-5.3% and PLC: 5.2%-5.9%). Thematic analysis of field notes showed that ANP acceptance was very high. Patient safety concerns were recorded related to care provided alongside ‘hybrid’ patient records. Conclusion: We found high physician acceptance of ANP based on documented comments and observed usage. We posit a high potential for EHRs such as ANP to support improved care coordination which remains partly realized.

Introduction: The PECARN head CT scan rule helps to identify children at risk of clinically important Traumatic Brain Injury (ciTBI) but many children fall in a grey zone while applying the rule (observation vs. CT scan). The C-3PO rule identifies children at risk of skull fracture. The Ste-Justine Head Trauma pathway comprises both rules for the management of all children younger than two years who suffered a head trauma. The primary objective of this study was to measure the capacity of the Ste-Justine Head Trauma pathway to identify children with ciTBI. Methods: This was a retrospective study of all children younger than two years old who visited a university affiliated pediatric emergency department (ED) for a head trauma between Sept. 2013 and Aug. 2015. Participants were all patients admitted for a head trauma and a randomly selected sample of 5% of non-admitted patients. Independent variables of the algorithm were recorded for each patient. The primary outcome was the presence of a ciTBI defined by any of the following secondary to TBI: death, neurosurgery, intubation of more than 24 hours or hospitalization for more than one night. Participants were identified using the computerized database of the ED and all charts were reviewed using a standardized report form. The primary analysis was the proportion of children with ciTBI accurately identified using the pathway. A secondary analysis was to compare the performance of the pathway in comparison to the PECARN rule alone. Results: During the study period a total of 2,258 children were seen in the ED for head trauma. The charts of all hospitalized (n=100) and a sample (n= 101) of non-hospitalized children were reviewed. A ciTBI was found in 26 participants (3 neurosurgical interventions, 4 intubated and 26 admitted > one night). Among them, 18 were classified at high risk, 7 at moderate risk and 1 at low risk according to the clinical pathway. Using the PECARN rule alone would have classified 17 at high risk, 5 at moderate risk and 4 at low risk. Using the pathway to the entire population would yield the following risk of cTBI: High-risk: 25%; moderate risk: 1%; low risk < 0.1%. Conclusion: The Ste-Justine Head Trauma pathway effectively identifies children younger than two years at risk of ciTBI following head trauma while triaging effectively children at low risk. The pathway is more sensitive than the PECARN rule to identify children at risk of ciTBI.

Introduction: Although alcohol use increases the risk of experiencing a traumatic brain injury (TBI), it remains unclear whether outcomes in alcohol-impaired patients are different from those of unimpaired patients. The objective of this study was to evaluate the effect of alcohol on length of stay (LOS) and mortality in patients with major TBI. Methods: Using data collected from the Nova Scotia Trauma Registry, we performed a retrospective analysis of all patients with major TBI (defined as having an abbreviated injury score (AIS) head ≥3) seen in Nova Scotia hospitals between 2002 and 2013. Patients were compared by blood alcohol concentration (BAC) at time of injury: negative (0-1.9 mmol/L), low (2-21 mmol/L), and moderate/high (≥22 mmol/L). A logistic regression model was constructed to test for outcomes and adjusted for the effects of age, gender, location, injury severity score (ISS), and BAC level. Results: In a twelve-year period, there were 4152 major TBI patients in Nova Scotia. Alcohol testing was performed in 43% of cases (80% male, mean age 44±20 years), with 48% having a positive BAC. Mean acute LOS was similar for all three BAC groups. Increasing age (odds ratio [OR]=1.01; p<0.001), high ISS (OR=4.92; p<0.001), injuries occurring outside of Halifax Regional Municipality (OR=1.72; p<0.001), and having a lower BAC level (OR = 0.99; p<0.001) independently predicted mortality. Conclusion: Our findings suggest that low BAC levels are associated with increased mortality in major TBI patients. Further study is warranted to elucidate alcohol’s mechanism in TBI outcomes.

Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability in Nova Scotia. TBI occurs in approximately 50% of major trauma seen annually in the province. The purpose of this study was to describe the characteristics and patterns of major TBI seen in Nova Scotia over a 12-year period. Methods: This was a retrospective case series. Data were obtained from the Nova Scotia Trauma Registry for all patients presenting with major TBI (abbreviated injury score [AIS] head ≥3) between 2002 and 2013. Injury rates were calculated on the basis of 100,000 population (all ages) using population estimates from Statistics Canada. Results: Overall, 4152 major TBI patients were seen in Nova Scotia hospitals during the study period. Mean age of TBI patients was 51±25 years; 73% were male. The majority of injuries were the result of blunt trauma (93%), with relatively few major TBIs resulting from penetrating trauma (7%). The most common mechanisms of injury were falls (44%) and motor vehicle crashes (27%). Analysis of census-based subpopulations of the province showed that injury rates varied significantly among counties (from 25 to 63 per 100,000 population). We observed an increase in the number of major TBI patients over twelve years. Conclusion: Our findings suggest significant regional variation in major TBI rates in Nova Scotia. There are ongoing needs for prevention and intervention efforts that focus on unintentional falls and motor vehicle crashes, especially in older adults. These results also suggest that geographically targeted efforts may be warranted.