Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures & Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.

Background: Urinary tract infections (UTI) are a common emergency department (ED) presentation. Urine cultures (UC) are frequently ordered to confirm the diagnosis, however, it can be challenging to differentiate between a true infection and asymptomatic bacteriuria (ASB) which does not generally benefit from antibiotics. This over-treatment of ASB leads to serious adverse side effects, growing antimicrobial resistance and increased healthcare costs. By reducing inappropriate ED urine culture testing, we can concomitantly avoid the false positives that contribute to this large-scale problem. Aim Statement: We aimed to reduce ED urine culture testing at Credit Valley Hospital, a large community hospital based in Mississauga, Ontario by 30%, from a baseline average of 97 cultures per 1000 ED visits in 2017, to 68 cultures per 1000 ED visits by year end 2019. Measures & Design: Multiple PDSA cycles were ran with our multi-disciplinary ED team. Our interventions to encourage rational urine culture testing are three-fold, including (1) medical directive optimization (removal of routine sending of UC), (2) individualized physician feedback and (3) physician education with introduction of a clinical decision aid. Our outcome measure is rate of UC per 1000 ED patient visits with a balance measure of rate of 30-day ED return visit of hospital admission for patients with a UTI. Evaluation/Results: Despite a parallel surge in ED volumes, we observed a significant decrease in urine culture testing, from an annual average of 97 cultures per 1000 ED visits to 60 cultures per 1000 ED visits in 2019 year-to-date. There was no increase in the rate of ED 30-day return visit or admission for UTI or a diagnostic equivalent. Discussion/Impact: Our multipronged approach effectively decreased the rate of UC testing during the study period. ED physicians provide higher quality care with judicious use of resources to guide diagnosis and management. Active ongoing interventions include our transition to a 2-step UC order protocol (uncoupling urinalysis with culture) using BD vacutainer urine collection products, which will allow for 48 hour storage of uncompromised urine. Further work will leverage our knowledge and experience with optimizing urine culture testing to other culture specimens.

Background: Increasing Emergency Department (ED) stretcher occupancy with admitted patients at our tertiary care hospital has contributed to long Physician Initial Assessment (PIA) times. As of Oct 2019, median PIA was 2.3 hours and 90th percentile PIA was 5.3 hours, with a consequent 71/74 PIA ranking compared to all Ontario EDs. Ambulatory zone (AZ) models are more commonly used in community EDs compared to tertiary level EDs. An interdisciplinary team trialled an AZ model for five days in our ED to improve PIA times. Aim Statement: We sought to decrease the median PIA for patients in our ED during the AZ trial period as compared to days with similar occupancy and volume. Measures & Design: The AZ was reserved for patients who could walk from a chair to stretcher. In this zone, ED rooms with stretchers were for patient assessment only; when waiting for results or receiving treatment, patients were moved into chairs. We removed nursing assignment ratios to increase patient flow. Our outcome measure was the median PIA for all patients in our ED. Our balancing measure was the 90th percentile PIA, which could increase if we negatively impacted patients who require stretchers. The median and 90th percentile PIA during the AZ trial were compared to similar occupancy and volume days without the AZ. Additional measures included ED Length of Stay (LOS) for non-admitted patients, and patients who leave without being seen (LWBS). Clinicians and patients provided qualitative feedback through surveys. Evaluation/Results: The median PIA during the AZ trial was 1.5 hours, compared to 2.1 hours during control days. Our balancing measure, the 90th percentile PIA was 3.7 hours, compared to 5.0 during control days. A run chart revealed both median and 90th percentile PIA during the trial were at their lowest points over the past 18 months. The number of LWBS patients decreased during the trial; EDLOS did not change. The majority of patients, nurses, and physicians felt the trial could be implemented permanently. Discussion/Impact: Although our highly specialized tertiary care hospital faces unique challenges and high occupancy pressures, a community-hospital style AZ model was successful in improving PIA. Shorter PIA times can improve other quality metrics, such as timeliness of analgesia and antibiotics. We are working to optimize the model based on feedback before we cycle another trial. Our findings suggest that other tertiary care EDs should consider similar AZ models.

Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.

Background: Massive hemorrhage protocols (MHPs) streamline the complex logistics required for prompt care of the bleeding patient, but their uptake has been variable and few regions have a system to measure outcomes from these events. Aim Statement: We aim to implement a standardized MHP with uniform quality improvement (QI) metrics to increase uptake of evidence-based MHPs across 150-hospitals in Ontario between 2017 and 2021. Measures & Design: We performed ongoing PDSA cycles; 1) stakeholder analysis by surveying the Ontario Regional Blood Coordinating Network (ORBCoN), 2) problem characterization and Ishikawa analysis for key QI metrics based on areas of MHP variability in 150 Ontario hospitals using a web-based survey, 3) creation of a consensus MHP via a modified Delphi process, 4) problem characterization at ORBCoN for the design of a freely available toolkit for provincial implementation by expert working groups, 5) design of 8 key QI metrics by a modified Delphi process, and 6) identification of process measures for QI data collection by implementation metrics. Evaluation/Results: PDSA1-2; 150-hospitals were surveyed. 33% of hospitals lacked MHPs, mostly in smaller sites. Major areas for QI were related to activation criteria, hemostatic agents, protocolized hypothermia management, variable MHP naming, QI metrics and serial blood work requirements. PDSA3; 3 Delphi rounds were held to reach 100% expert consensus for 42 statements and 8 CQI metrics. Major areas for modification were protocol name, laboratory resuscitation targets, cooler configurations, and role of factor VIIa. PDSA4; adaptable toolkit is under development by the steering committee and expert working groups. Implementation is scheduled for Spring 2020. PDSA5; the 8 CQI metrics are: TXA administration < 1 h, RBC transfusion < 15 min, call to transfer for definitive care < 60 min, temp >35°C at end of protocol, Hgb kept between 60-110g/L, transition to group-specific RBC by 90 min, appropriate activation defined by ≥6 units RBC in the first 24 hours, and any blood component wastage. Discussion/Impact: MHP uptake, content, and tracking is variable. A standardized MHP that is adaptable to diverse settings decreases complexity, improves use of evidence-based practices, and provides a platform for continuous QI. PDSA6 will occur after implementation; we will complete an implementation survey, and design a pilot and feasibility study for prospective tracking of patient outcomes using existing prospectively collected inter-hospital and provincial databases.

Introduction: Despite an overall decline in opioid prescriptions in Canada, healthcare visits, hospitalizations, and deaths due to opioid-related harms continue to rise for children. Clinicians urgently require high quality synthesized evidence to inform personalized decisions regarding opioid use for children. The objective of this systematic review was to examine the association between short-term therapeutic exposure to opioids and development of opioid use disorder. Methods: A medical librarian conducted a comprehensive search of 10 databases from inception to May 2019. Two authors independently assessed studies for inclusion. Studies were eligible if they reported primary research in English or French, and study participants had short (<14 days) or non-specific duration of therapeutic exposure to opioids before age 18 years. Primary outcome was the development of an opioid use disorder; secondary outcomes included opioid addiction, dependence, misuse, and abuse. Data extraction involved two independent reviewers utilizing a standardized form. Methodological quality was assessed using the NIH tools for observational studies. Results are described narratively. Results: The search identified 4,072 unique citations; 82 were selected for review, and 17 were included (3 retrospective cohort, 4 prospective cohort, and 10 cross-sectional). All studies took place in the USA. A total of 1,562,503 participants were analyzed. Nine studies were administered in schools, 3 used administrative data. While most settings were non-specific, 1 study examined opioid use in dentistry, 1 in trauma, and 1 in organized sports. One comparative study showed an association between short-term therapeutic use and opioid misuse. Two studies showed opioid related adverse events (e.g., overdose) among cohorts exposed to short-term use. The remaining 14 studies did not specify duration of exposure; therefore, confirming whether misuse was due to short-term therapeutic exposure was not possible. Conclusion: A small number of studies in this review suggest an association between short-term opioid use and opioid misuse; however, further analysis is underway with consideration of methodological limitations of the individual studies (final results pending). Careful consideration of the risk and benefits of short-term opioid use should be undertaken prior to prescribing opioids. PROSPERO Registration Number: 122681.

Introduction: Emergency care serves as an important health resource for First Nations (FN) persons. Previous reporting shows that FN persons visit emergency departments at almost double the rate of non-FN persons. Working collaboratively with FN partners, academic researchers and health authority staff, the objective of this study is to investigate FN emergency care patient visit statistics in Alberta over a five year period. Methods: Through a population-based retrospective cohort study for the period from April 1, 2012 to March 31, 2017, patient demographics and emergency care visit characteristics for status FN patients in Alberta were analyzed and compared to non-FN statistics. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage Acuity Scale (CTAS)). Means and standard deviations (medians and interquartile ranges (IQR)) describe continuous variables (e.g., distances) as appropriate for the data distribution. These descriptions are repeated for the FN and non-FN populations, separately. Results: The data set contains 11,686,288 emergency facility visits by 3,024,491 unique persons. FN people make up 4.8% of unique patients and 9.4% of emergency care visits. FN persons live further from emergency facilities than their non-FN counterparts (FN median 6 km, IQR 1-24; vs. non-FN median 4 km, IQR 2-8). FN visits arrive more often by ground ambulance (15.3% vs. 10%). FN visits are more commonly triaged as less acute (59% CTAS levels 4 and 5, compared to non-FN 50.4%). More FN visits end in leaving without completing treatment (6.7% vs. 3.6%). FN visits are more often in the evening – 4:01pm to 12:00am (43.6% vs. 38.1%). Conclusion: In a collaborative validation session, FN Elders and health directors contextualized emergency care presentation in evenings and receiving less acute triage scores as related to difficulties accessing primary care. They explained presentation in evenings, arrival by ambulance, and leaving without completing treatment in terms of issues accessing transport to and from emergency facilities. Many factors interact to determine FN patients’ emergency care visit characteristics and outcomes. Further research needs to separate the impact of FN identity from factors such as reasons for visiting emergency facilities, distance traveled to care, and the size of facility where care is provided.

Introduction: Epidemiologic and modeling studies suggest that between 45 and 70% of individuals with chronic hepatitis C virus (HCV) infection in Canada remain undiagnosed. The Canadian Association for the Study of the Liver (CASL) recommends one-time screening of baby boomers (1945-1975). Screening programs in the US have shown a very high prevalence of previously undiagnosed HCV among patients seen in the emergency department (ED). We sought to assess the feasibility of implementing a targeted birth-cohort HCV screening program in a Canadian ED setting. Methods: Patients born from 1945 to 1975 presenting to the ED of a downtown Toronto hospital were offered HCV testing. Patients with life-threatening conditions, unable to provide verbal consent in English or intoxication were excluded. Blood samples were collected by finger prick on Dried Blood Spot (DBS) collection cards and tested for anti-HCV antibody with reflex to HCV RNA. Patients with positive HCV RNA were referred to a liver specialist. Results: During a 27-month period (July 2017 - Sept 2019), 8363 patients in the birth cohort presented to the ED during daytime hours. 80% (6714) met eligibility criteria, and 48.4% (3247) were offered testing. Screening was performed by non-medical staff (mean 8/day, median spots on DBS 4). 345 (10.6%) had been previously tested, and 639 (19.7%) declined. 2136 (65.8%) patients underwent testing: median age 58.4 years (40-82), 1117 male (52.3%). Of these, 45 patients (2.1%; 95% CI 1.5%-2.7%) were anti-HCV positive: 32 (76.2%) were HCV RNA positive, 10 (23.8%) negative and 3 not done due to inadequate DBS sample. 26 patients (81.3%) were linked to care and 3 (9.4%) lost to follow-up. HCV prevalence in the ED was significantly higher than the general Canadian population (2.1% vs 0.7%; p < 0.0001) but much lower than reported rates in American EDs (2.1% vs 10.3%; p < 0.0001). Conclusion: Acceptance of HCV screening in the ED birth cohort was high and easily performed using DBS to ensure the majority of positive samples were tested for HCV RNA. Challenges included implementation that limited number of people tested, and linkage to care for HCV positive patients. HCV prevalence among this ED birth cohort was higher than the general population but lower than seen in the ED in the US. This may in part be due to exclusion of individuals with more severe medical issues, refusal by higher risk subgroups, or population and healthcare system differences between countries.

Introduction: Women experiencing early pregnancy loss or threatened loss frequently seek care in emergency departments (ED) or early pregnancy clinics (EPC). The dearth of existing qualitative studies has left understudied questions about how these women perceive their healthcare and which strategies best meet their supportive care needs, particularly in the Canadian context. The objective of this study was to deepen our understanding of these women's experiences and gain insight into how clinicians and healthcare services can lessen the impact of this traumatic event on patients and their families. Methods: We conducted a descriptive qualitative study of women who presented to the ED or EPC at an urban tertiary care hospital and an urban community hospital for early pregnancy loss or threatened loss. Purposive sampling was used to recruit patients for in-depth, one-on-one telephone interviews conducted 4-6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Data analysis was led by two qualitative researchers with support from a multi-disciplinary research team following standard thematic analysis techniques. Results: Interviews were completed with 59 women between July 2018 and August 2019. Participants ranged in age from 22 to 47 years and reflect the diversity of the multicultural city where the study occurred. Our analysis revealed that the medicalization and normalization of early pregnancy complications among ED and EPC clinicians is at odds with women's general lack of knowledge about the frequency, personal risk, causation, duration, and physical intensity of the miscarriage experience. Women identified the value of rapid access to appointments, point of care ultrasound, detailed care plans, and knowledgeable advice as key to lessening the physical and emotional trauma related to early pregnancy loss. Conclusion: This research highlights the physical, emotional, and psychological complexity of a medical situation frequently minimized within the current healthcare system. The results impart important knowledge about which aspects of ED and EPC care are most valued by women experiencing early pregnancy loss or threatened loss and demonstrate the clear need for women and their families to be provided with more education about the totality of the early pregnancy experience, including the possibility of pregnancy complications and loss.

Introduction: Pain and bleeding complicate 30% of pregnancies threatening viability. The objective of this systematic review is to evaluate the role of a single progesterone level in predicting viability. Methods: We comprehensively searched MEDLINE, Embase (OVID), CINAHL and Cochrane databases from inception to July 2019. We included English language studies that enrolled symptomatic first trimester pregnant patients, measured progesterone and reported viability (miscarriage, ectopic or viable). We excluded studies with patients who had progesterone treatment, or conception after induced ovulation/invitro fertilization. We extracted patient characteristics, study setting, mean progesterone, the cut off value and outcome (viability). The quality of the included studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We extracted data for 2X2 tables and report mean, standard deviation (SD), sensitivity, specificity, positive and negative predictive values (PPV, NPV). Results: Of the 689 studies screened, 51 studies with 15783 patients were included (1 randomized control trial, 36 prospective, 9 retrospective, 5 prospective case control studies) and 7553 were viable pregnancies. Of the 31 studies (n = 10998) that reported ectopic, 1661 patients were diagnosed with ectopic pregnancy. In 35 studies (n = 6003) that reported mean and SD, the levels were higher in viable (26.7 ± 11.2ng/ml) than non-viable (9.5 ± 5.9ng/ml; p < 0.001) or ectopic pregnancy 9.5 ± 6.8ng/ml (p < 0.001). The pooled diagnostic characteristics at different cut-off values were: <6.3ng/mL (9 studies; N = 6033) sensitivity 65.0% (95%CI 63.5,66.5), specificity 97.3% (95%CI 95.5, 98.5), PPV 99.4% (95%CI 99.1,99.7) and NPV 27.4 (95%CI 26.6,28.4); <10 ng/mL (12 studies with 5743 participants) sensitivity 65.0% (95% CI 63.5, 66.5), specificity of 97.3% (95%CI 95.5, 98.5), PPV 99.4% (95% CI 99.1, 99.7) and NPV 27.4% [95% CI 26.5, 29.4); 11-20 ng/mL (24 studies with 7141 participants) sensitivity 77.3% (95% CI 76.2,78.4), specificity 64.6% (95% CI 63.2, 65.9), PPV 73.2% [95% CI 72.3, 73.9) and NPV 69.5% (95% CI 70.7, 72.5). There was low risk of bias for patient selection, index test and low concern regarding applicability. The highest risk (82% of studies) was due to outcome ascertainment bias due to non-blinding of index and additional tests. Conclusion: A single progesterone value is useful in predicting viability of pregnancy among symptomatic patients.

Introduction: Acute bloody diarrhea obligates rapid and accurate diagnostic evaluation; few studies have described such cohorts of children. Methods: We conducted a planned secondary analysis employing the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) acute gastroenteritis study cohort to describe the characteristics of children with acute bloody diarrhea, compared to a cohort of children without hematochezia. Children <18 years of age presenting to 2 pediatric tertiary care emergency departments (EDs) in Alberta, with ≥3 episodes of diarrhea and/or vomiting in the preceding 24 hours and <7 days of symptoms were consecutively recruited. Stools were tested for 17 viruses, bacteria and parasites. Primary outcomes were clinical characteristics and pathogens identified. Secondary outcomes included interventions and resource utilization. Results: Of 2257 children enrolled between October 2015 and August 2018, hematochezia before or at the index ED visit was reported in 122 (5.4%). Compared to children with nonbloody diarrhea, children with hematochezia had longer illness duration [59.5 vs. 41.5 hrs, difference 10.6, 95% CI 3.5, 19.9], more diarrheal episodes in a 24-hour period [8 vs. 5, difference 3, 95% CI 2, 4], and less vomiting [55.7% vs. 91.1%; difference -35.3%; 95% CI -44.7, -26.3]. They received more intravenous fluids [32.0% vs. 18.3%; difference 13.7%, 95% CI 5.5, 23.0], underwent non-study stool testing [53.7% vs. 4.8%; difference 49.0%, 95% CI 39.6, 58.0], experienced longer ED visits [4.1 vs. 3.3 hours, difference 0.9, 95% CI 0.3, 1.0] and were more likely to have repeat healthcare visits within 14 days [54.8% vs. 34.2%; difference 20.6%, 95% CI 10.8, 30.1]. A bacterial enteric pathogen was found in 31.9% of children with hematochezia versus 6.6% without bloody diarrhea (difference 25.4%, 95% CI 17.2, 34.7). In children with hematochezia, the most commonly detected bacteria were Salmonella spp. (N = 15), Shiga toxin-producing E. coli (N = 9), Campylobacter spp. (N = 7), and Shigella spp. (N = 5). Viruses were detected in 32.8% of children with bloody diarrhea, most commonly adenovirus (N = 15), norovirus (N = 14), sapovirus (N = 8) and rotavirus (N = 7). Conclusion: Children with hematochezia differed clinically from those without hematochezia and required more healthcare resources. While bacterial etiologies are common, several viruses were also detected.

Introduction: Cannabinoid Hyperemesis Syndrome (CHS) in pediatric patients is poorly characterized. Literature is scarce, making identification and treatment challenging. This study's objective was to describe demographics and visit data of pediatric patients presenting to the emergency department (ED) with suspected CHS, in order to improve understanding of the disorder. Methods: A retrospective chart review was conducted of pediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one pediatric and one pediatric/adult (combined annual pediatric census 40,550) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant. Results: 242 patients met criteria for review. 39 were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female). 87% were triaged as either CTAS-2 or CTAS-3. 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. 69% of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain, and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). 89% of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous (IV) fluids, and 22% receiving analgesics. Normal saline was the most used IV fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74%, with 31% of these given the formal diagnosis of CHS. 62% of patients had another visit to the ED within 30 days (prior to or post sentinel visit), 59% of these for similar symptoms. Conclusion: This study of pediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly one third. Many received extensive workups and most had multiple clustered visits to the ED.

Introduction: Digital distraction is being integrated into pediatric pain care, but its efficacy is currently unknown. We conducted a systematic review to determine the effect of digital technology distraction on pain and distress for children experiencing acutely painful conditions or medical procedures. Methods: We searched eight online databases (MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, IEEE Xplore, Ei Compendex, Web of Science), grey literature sources, scanned reference lists, and contacted experts for quantitative studies where digital technologies were used as distraction for acutely painful conditions or procedures in children. Study selection was performed by two independent reviewers with consensus. One reviewer extracted relevant study data and another verified it for accuracy. Appraisal of risk of bias within studies and the certainty of the body of evidence were performed independently in duplicate, with the final appraisal determined by consensus. The primary outcomes of interest were child pain and distress. Results: Of 3247 unique records identified by the search, we included 106 studies (n = 7820) that reported on digital technology distractors (e.g., virtual reality; videogames) used during common procedures (e.g., venipuncture, minor dental procedures, burn treatments). We located no studies reporting on painful conditions. For painful procedures, digital distraction resulted in a modest but clinically important reduction in self-reported pain (SMD -0.48, 95% CI -0.66 to -0.29, 46 RCTs, n = 3200), observer-reported pain (SMD -0.68, 95% CI -0.91 to -0.45, 17 RCTs, n = 1199), behavioural pain (SMD -0.57, 95% CI -0.94 to -0.19, 19 RCTs, n = 1173), self-reported distress (SMD -0.49, 95% CI -0.70 to -0.27, 19 RCTs, n = 1818), observer-reported distress (SMD -0.47, 95% CI -0.77 to -0.17, 10 RCTs, n = 826), and behavioural distress (SMD -0.35, 95% CI -0.59 to -0.12, 17 RCTs, n = 1264) compared to usual care. Few studies directly compared different distractors or provided subgroup data to inform applicability. Conclusion: Digital distraction provides modest pain and distress reduction for children undergoing painful procedures; its superiority over non-digital distractors is not established. Healthcare providers and parents should strongly consider using distractions as a pain-reduction strategy for children and teens during common painful procedures (e.g., needle pokes, dental fillings). Context, child preference, and availability should inform the choice of distractor.

Introduction: Lacerations are common in children presenting to the emergency department (ED). They are often uncooperative when sutures are needed and may require procedural sedation. Few studies have evaluated intranasal (IN) ketamine for procedural sedation in children, with doses from 3 to 9 mg/kg used mostly for dental procedures. In a previous dose escalation trial, DosINK-1, 6 mg/kg was found to be the optimal IN ketamine dose for procedural sedation for sutures in children. In this trial, we aim to further evaluate the efficacy of this dose. Methods: We conducted a multicentre single-arm clinical trial. A convenience sample of 30 uncooperative children between 1 and 12 years (10 to 30 kg) with no cardiac or kidney disease, active respiratory infection, prior administration of opioid or sedative agents received 6 mg/kg of IN ketamine using an atomizer for their laceration repair with sutures in the ED. The primary outcome was defined as the proportion (95% CI) of patients who achieved an adequate procedural sedation evaluated with the PERC/PECARN consensus criteria. Results: Thirty patients were recruited from April 2018 to November 2019 in 2 pediatric ED. The median age was 3.2 (interquartile range(IQR), 1.9 to 4.7) years-old with laceration of more than 2 cm in 20 (67%) patients and in the face in 21 (70%) cases. Sedation was effective in 18 out of 30 children 60% (95%CI, 45 to 80), was suboptimal in 6 patients (20%) with a procedure completed with minimal difficulties, and unsuccessful in the remaining 6 (20%), all without serious adverse event. Similarly, 21/30 (70%) physicians were willing to reuse IN ketamine at the same doses and 25 parents (83%) would agree to the same sedation in the future. Median time to return to baseline status was 58 min (IQR, 33 to 73). One patient desaturated during the procedure and required transitory oxygen and repositioning. After the procedure, 1 (3%) patient had headache, 1 (3%) patient had nausea, and 2 (7%) patients vomited. Conclusion: A single dose of 6 mg/kg of IN Ketamine for laceration repair with sutures in uncooperative children is safe and facilitated the procedure in 60% (95%CI, 45 to 80) of patients, was suboptimal in 20% and unsuccessful in 20% of patients. As seen with IV ketamine, an available additional dose of IN ketamine for some children if needed could potentially increase proportion of successful sedation. However, the safety and efficacy of repeated doses needs to be addressed.

Introduction: Emergency Department (ED) utilization during pregnancy may be common, but data specific to universal healthcare systems like Canada are lacking, where pregnancy care is supposed to be standardized. The objective of this study was to quantify and characterize ED utilization among all Ontarian women who had a recognized pregnancy, including by trimester and within 42 days after pregnancy, and further stratified by pregnancy outcome. Methods: Utilizing provincial administrative health databases, this retrospective population-based cohort study included all recognized pregnancies in Ontario conceived between April 1, 2002 and March 31, 2017. Peri-pregnancy ED utilization was defined as any ED visit from 0-42 weeks’ gestation, or within 42 days after the end of pregnancy. Modified Poisson regression was used to generate relative risks (RR) and 95% confidence intervals (CI) for the outcome of any peri-pregnancy ED utilization in association with maternal characteristics. Results: Peri-pregnancy ED utilization occurred among 1,075,991 of 2,728,236 recognized pregnancies (39.4%), including among 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages, and 84.8% of threatened abortions. There were 22,802 (0.84%) ectopic pregnancies among all pregnancies in the cohort. ED utilization peaked in the first trimester and in the first week postpartum. A dose-response effect was seen in the number of peri-pregnancy ED visits in relation to certain maternal characteristics. Women residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39 to 3.49) for ≥ 3 ED visits, compared to those in urban areas. Women with 3-5 (OR 1.99 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49 to 3.61), or ≥ 7 (OR 7.59, 95% CI 7.39 to 7.78) pre-pregnancy comorbidities were more likely to have ≥ 3 peri-pregnancy ED visits than those with 0-2 comorbidities. Of all recognized pregnancies in the cohort, only 106,989 (3.9%) had an injury-related ED visit. Conclusion: Peri-pregnancy ED utilization occurs in nearly 40% of pregnancies, notably in the first trimester and immediately postpartum. Efforts are needed to streamline rapid access to ambulatory obstetrical care during these peak periods, when women are vulnerable to either a miscarriage, or a complication after a livebirth.

Introduction: Venipuncture is a frequent cause of pain and distress in the pediatric emergency department (ED). Distraction, which can improve patient experience, remains the most studied psychological intervention. Virtual reality (VR) is a method of immersive distraction that can contribute to the multi-modal management of procedural pain and distress. Methods: The main objectives of this study were to determine the feasibility and acceptability of Virtual Reality (VR) distraction for pain management associated with venipunctures and to examine its preliminary effects on pain and distress in the pediatric ED. Children 7-17 years requiring a venipuncture in the pediatric ED were recruited. Participants were randomized to either a control group (standard care) or intervention group (standard of care + VR). Principal clinical outcome was the mean level of procedural pain, measured by the verbal numerical rating scale (VNRS). Distress was also measured using the Child Fear Scale (CFS) and the Procedure Behavior Check List (PBCL) and memory of pain using the VNRS. Side effects were documented. Results: A total of 63 patients were recruited. Results showed feasibility and acceptability of VR in the PED and overall high satisfaction levels (79% recruitment rate of eligible families, 90% rate of VR game completion, and overall high mean satisfaction levels). There was a significantly higher level of satisfaction among healthcare providers in the intervention group, and 93% of those were willing to use this technology again for the same procedure. Regarding clinical outcomes, no significant difference was observed between groups on procedural pain. Distress evaluated by proxy (10/40 vs 13.2/40, p = 0.007) and memory of pain at 24 hours (2.4 vs 4.2, p = 0.027) were significantly lower in the VR group. Venipuncture was successful on first attempt in 23/31 patients (74%) in the VR group and 15/30 (50%) patients in the control group (p = 0.039). Five of the 31 patients (16%) in the VR group reported side effects Conclusion: The addition of VR to standard care is feasible and acceptable for pain and distress management during venipunctures in the pediatric ED. There was no difference in self-reported procedural pain between groups. Levels of procedural distress and memory of pain at 24 hours were lower in the VR group.

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

Introduction: Evidence is accumulating that a CT plus a CT angiogram (CTA) of the head and neck may be adequate to rule out subarachnoid haemorrhage (SAH) in patients with a thunderclap headache, thus potentially negating the need for lumbar puncture. One of the most widely cited objections to this strategy is the fear of detecting “incidental asymptomatic aneurysms,” lesions seen on angiography that are not in fact the cause of the patient's symptoms. Currently existing data on the background rate of aneurysms are based on cadaveric studies, invasive angiography, or MRI, and thus does not reflect the true rate of incidental aneurysms that would be detected using a CT plus CTA strategy. This study characterizes the rate of incidental aneurysms identified on CTA in an emergency department population. Methods: In this multicentre retrospective cohort study we analyzed the electronic medical records of all emergency department patients ≥ 18 years of age who underwent CTA of the head and neck over a two month period across four urban tertiary care emergency departments. Two independent reviewers evaluated the final radiology reports and extracted relevant data. The primary outcome of interest was the presence of incidental intracranial aneurysm, defined as a newly diagnosed aneurysm not associated with evidence of acute hemorrhage. Secondary outcomes included aneurysm location and size. Results: Of 739 charts meeting inclusion criteria, incidental intracranial aneurysms were detected in 21 cases or 2.85% (95% confidence interval, 1.77 - 4.32). An additional 20 aneurysms were identified but excluded from the analysis as they were previously known (n = 9) or were associated with evidence of acute hemorrhage (n = 11) and thus were not considered incidental. Of 21 patients with identified incidental aneurysms, 7 had multiple aneurysms. The most common aneurysm sites were internal carotid artery (n = 13), middle cerebral artery (n = 6) and anterior cerebral artery (n = 4). The average size of incidental aneurysm was 4.1 mm. Conclusion: The rate of incidental intracranial aneurysm among emergency department patients undergoing CTA of the head and neck is lower than many previously described estimates obtained through invasive angiography and MRI studies. To our knowledge, this is the first study on the prevalence of incidental intracranial aneurysms in an emergency department specific population and may therefore help guide clinicians when considering using a CT plus CTA rule out strategy for patients presenting with acute headache suspicious for SAH.

Introduction: Diagnosing deep vein thrombosis (DVT) is of critical importance because of its associated morbidity and mortality. Diagnosing DVT can be challenging in the Emergency Department (ED) due to inconsistent adherence to, and utilization of the Wells rule. Both the age-adjusted and clinical probability adjusted D-dimer have been shown to decrease ultrasound (US) utilization rates. We aimed to compare the safety and efficacy of the Wells score with D-dimer to the age-adjusted and clinical probability-adjusted D-dimer in Canadian ED patients tested for DVT. Methods: This was a health records review of ED patients investigated for DVT at two EDs over a two-year period. Inclusion criteria were ED physician ordered duplex ultrasonography or D-dimer for investigation of lower limb DVT. Patients under the age of 18 were excluded. DVT was considered to be present during the ED visit if DVT was diagnosed on duplex ultrasonography and was treated for acute DVT, or if the patient was subsequently diagnosed with pulmonary embolism (PE) or DVT during the next 30 days. Trained researchers extracted anonymized data. The Wells D-dimer, age-adjusted D-dimer, and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of duplex ultrasonography imaging and the false negative rate was calculated for each rule. Results: Between April 1st 2013 and March 31st 2015, there were 1,198 patients tested for DVT. Of the low and moderate clinical pretest probability patients (Wells score ≤ 2), only 436 had a D-Dimer test and were eligible for our analysis. The average age of the patients was 59, 56% were female, and 4% had a malignancy. 207/436 patients (47.4%, 95%CI 42.8-52.2%) would have had US imaging for DVT if the age-adjusted D-dimer rule was used. 214/436 patients (49.1%, 95%CI 44.4-53.8%) would have had imaging for DVT if the clinical probability-adjusted D-dimer was used. If the Wells rule was used with the standard D-dimer cutoff of 500, 241/436 patients (55.2%, 95%CI 50.6-59.9%) would have had imaging for DVT. The false-negative rate for the Wells rule was 1.5% (95%CI 0.5-4.4%). The false-negative rate for the age-adjusted D-dimer rule was 1.3% (95%CI 0.4-3.8%). The false-negative rate for the clinical-probability adjusted D-Dimer was 1.8% (95%CI 0.7-4.5%). Conclusion: In comparison with the approach of the Wells score and D-dimer, both the age-adjusted and clinical probability-adjusted D-dimer diagnostic strategies could reduce the proportion of patients who require US imaging.