Introduction: Discomfort exists discussing goals of care with families of children with advanced life-threatening illnesses. There also exists important variability in the management of these patients. This study seeks to explore the perceptions of pediatric specialists involved in the care of children with life-threatening illnesses with regards to goals of care discussions and management during acute unexpected deteriorations. Methods: This single center survey study used 4 scenarios of children presenting to the emergency department with respiratory distress. Scenarios included patients with hypoplastic left heart syndrome, static encephalopathy, spinal muscular atrophy and refractory leukemia. Questions following each vignette were identical. Physicians from the specialties most involved in these scenarios completed the survey by email or in person. Data analysis used SPSS v.20 (IBM Inc.). Related samples non-parametric tests compared participants’ Likert scale answers. Results: Between May 2015 and May 2016, 60 participants completed the study; 14 were excluded (>60% missing answers). Most (80.4%) participants reported an interest in pediatric palliative care; 71.7% had 0-3 formal trainings. Participants believed goals of care were best discussed before an acute deterioration. Acute deteriorations were not seen as an opportune moment to initiate discussions about goals of care. However, validating these previous wishes was necessary, given that not discussing them was judged unacceptable by the participants. Pediatric specialists were seen as the most suitable teams to initiate these discussions, while the emergency department's role in these discussions was unclear. Several management options were less acceptable for the patient with static encephalopathy. Conclusion: Discussing goals of care during acute illness exacerbation involves many stakeholders, who may not always be available at critical times. Advanced care planning with these families is essential to prepare them for acute health events.

Introduction: La réanimation par circulation extracorporelle (R-CEC) permet potentiellement d'améliorer la survie de patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH) réfractaire aux traitements habituels. Cette technique, se pratiquant généralement en centre hospitalier (CH), doit être réalisée le plus précocement possible. Un transport vers le CH en temps opportun est donc nécessaire. Cette étude vise à décrire la durée nécessaire des manœuvres de réanimation préhospitalières afin d'optimiser le moment du départ vers le CH dans le but d'obtenir un maximum de retour de circulation spontanée (RCS) préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients éligibles à une R-CEC selon les critères locaux ont été inclus (<65 ans, rythme initial défibrillable, arrêt témoigné avec réanimation par un témoin). Les patients ayant eu un arrêt devant les paramédics ont été exclus, tout comme ceux avec un RCS avant l'arrivée des services préhospitaliers. Nous avons calculé la sensibilité et la spécificité à différents seuils afin de prédire un RCS préhospitalier et une survie au congé hospitalier. Une courbe ROC a également été construite. Results: Un total de 236 patients (207 hommes et 29 femmes) d'un âge moyen de 52 ans (±10) ont été inclus dans l’étude, parmi lesquels 93 (39%) ont survécu jusqu’à leur congé hospitalier et 136 (58%) ont obtenu un RCS préhospitalier. Le délai moyen avant leur RCS était de 13 minutes (±10). Plus de 50% des survivants avaient eu un RCS moins de 8 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 90% avant 24 minutes. Plus de 50% de tous les RCS survenaient dans les 10 premières minutes de réanimation et plus de 90% dans les 31 premières minutes. La courbe ROC montrait visuellement que le délai avant le RCS maximisant la sensibilité et la spécificité pour prédire la survie chez ces patients était à 22 minutes (Sensibilité = 90%, spécificité = 78%; aire sous la courbe = 0,89 [intervalle de confiance à 95% 0,84-0,93]). Conclusion: Le départ vers le CH pourrait être considéré pour ces patients entre 8 et 24 minutes après l'initiation des manœuvres. Une période de réanimation de 22 minutes semble être le meilleur compromis à cet égard.

Introduction: Studies suggest that acute pain evolution after an emergency department (ED) visit has been associated with the development of chronic pain. Using group-based trajectory modeling (GBTM), we aimed to evaluate if ED discharged patients with similar pain intensity profiles of change over 14 days are associated with chronic pain at 3 months. Methods: This is a prospective cohort study of patients aged 18 years or older who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity level (0-10 numeric rating scale). Three months post-ED visit, participants were interviewed by phone to report their pain intensity related to the initial pain. Results: A total of 305 patients were retained at 3 months (mean age ± SD: 55 ± 15 years, 49% women). Using GBTM, six distinct pain intensity trajectories were identified during the first 14 days of the acute pain period; two linear one with moderate or severe pain during the follow-up (representing almost 40% of the patients) and four cubic polynomial order trajectories, with mild or no-pain at the end of the 14 days (low final pain). Twelve percent (11.9; ±95%CI: 8.2-15.4) of the patients had chronic pain at 3 months. Controlling for age, sex and types of pain condition, patients with trajectories of moderate or severe pain and those with only severe pain were 5.1 (95%CI: 2.2-11.8) and 8.2 (95%CI: 3.4-20.0) times more likely to develop chronic pain at 3 months, respectively, compared to the low final pain group. Conclusion: Trajectories could be useful to early identification of patients at risk of chronic pain.

Introduction: The objective of the study was to evaluate the acute pain intensity evolution in ED discharged patients using Group-based trajectory modeling (GBTM). This method identified patient groups with similar profiles of change over time without assuming the existence of a particular pattern or number of groups. Methods: This was a prospective cohort study of ED patients aged ≥18 years with an acute pain condition (≤ 2 weeks) and discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level (0-10 numeric rating scale) and pain medication use. Results: Among the 372 included patients, six distinct post-ED pain intensity trajectories were identified: two started with severe levels of pain, one remained with severe pain intensity (12.6% of the sample) and the other ended with moderate pain intensity level (26.3%). Two other trajectories had severe initial pain, one decreased to mild pain (21.7%) and the other to no-pain (13.8%). Another trajectory had moderate initial pain which decreased to a mild level (15.9%) and the last one started with mild pain intensity and had no pain at the end of the 14-day (9.7%). The pain trajectory patterns were significantly associated with age, type of painful conditions, pain intensity at ED discharge, and with opioid consumption. Conclusion: Acute pain resolution following an ED visit seems to progress through six different trajectory patterns that are more informative than simple linear models and could be useful to adapt acute pain management in future research.

Introduction: Alcohol use disorder (AUD) is a chronic relapsing and highly comorbid disease. Patients suffering from AUD are frequently seen in the emergency department (ED) presenting intoxicated or in withdrawal. Brief interactions in the ED are often the only portal of entry to the healthcare system for many of these patients. Oral naltrexone and long acting injectable naltrexone are effective treatment options for AUD associated with decreased cravings, shorter length of hospital stay, and lower cost of healthcare utilization. This study's objective was to perform a systematic review of the literature evaluating initiation of naltrexone in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing initiation of naltrexone in patients (≥18 years) to standard care in the ED were included. Two reviewers independently screened titles and abstracts, reviewed full text articles for inclusion, assessed quality of the studies, and extracted data. Results: The search strategy yielded 183 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 10 articles were retrieved for full text review. There were no published RCTs that examined naltrexone initiation in the ED. There is one ongoing study being conducted in New York, which aims to assess naltrexone initiation in the ED and measure health outcomes and quality of life of study participants, as well as potential healthcare cost savings. Conclusion: The lack of published research in this area demonstrates a significant gap in knowledge. It is clear that well-designed RCTs are needed to evaluate the effectiveness of initiating naltrexone for those with AUD at the ED visit.

Innovation Concept: Competence in procedural skills is vital within the emergency department. Challenging procedures such as cricothyroidotomy are difficult to master as they are rare and hard to train for. Additionally, common procedures such as chest tube insertions require practice to become sufficiently competent. Opportunities to hone these skills are essential in residency training. This project aimed to create instructional video modules for specific emergency medicine (EM) procedures and to gauge its utility as an adjunctive resource for procedural learning in the EM residency curriculum. Methods: Tutorial videos for clamshell thoracotomy, cricothyroidotomy, and chest tube insertion were filmed within a cadaver lab with step-by-step instructions. The footage was edited and overlaid with a prepared audio narration using Camtasia®/Apple® Video Editing software. These videos were embedded within modules that included foundational knowledge relevant to the procedures including anatomy, physiology and pathophysiology. The modules were peer-edited by licensed EM staff physicians and distributed to EM residents and staff physicians for analysis. Qualitative and quantitative analysis relied upon participants’ answers to questions and a Modified Task Value Scale (measures the value of a module for overall learning), respectively. Curriculum, Tool or Material: Ten participants were included in the analysis, including EM residents (n = 6) and staff emergency physicians (n = 4). Qualitative feedback suggested that positive aspects of the modules included visuals, content, narration, and review of anatomy. Negative aspects included the lack of indications for procedures, technical details, real patient examples, and a speed up function. Quantitative feedback resulted in scores of 4 and above out of 5 (1 = lowest value, 5 = highest value) on the Motivated Task Value Scale across all aspects for all the modules. Furthermore, analysis revealed an average score of 3.9/5 for inclination to access more modules such as these, and a score of 4.4/5 for overall perception of the modules. Conclusion: Participants found the video modules valuable to their learning, both qualitatively and quantitatively. This study was limited by a small sample size of modules and a low number of participants. Furthermore, a more detailed analysis with further measures, including self-efficacy and self-confidence, would yield more comprehensive conclusions. However, video modules provide an effective and easily accessible adjunctive tool to acquire skill and confidence with EM procedures, for medical learners and staff physicians.

Introduction: According to the Public Health Agency of Canada, the rate of invasive Group A Streptococcus (iGAS) has more than doubled since it first became a notifiable disease in 2000. Our objectives were to describe the clinical and laboratory characteristics of iGAS in a geographic area that sees a relatively high volume of cases annually. Methods: We conducted a retrospective chart review of all adult and pediatric patients presenting to the Thunder Bay Regional Health Sciences Centre Emergency Department from January 2016 to December 2017 with a hospital discharge diagnosis of iGAS infection using ICD-10 codes. Patient demographics, host characteristics, triage vital signs, laboratory values, culture sites, and disposition were analyzed using univariate and bivariate statistics. Results: Forty-five cases of iGAS were identified over 2 years, with a mean age of 45 years (SD 18). The most prevalent associations were male sex (69%), diabetes mellitus (44%), current or previous alcohol abuse (38%), and current or previous intravenous drug use (33%). Prevalence of iGAS was roughly two times the national average in 2016 (11.5 per 100,000) and four times the national average in 2017 (25.5 per 100,000). Mean triage vital signs included a systolic blood pressure of 126 mmHg (SD 24), diastolic blood pressure of 73 mmHg (SD 16), temperature of 37.3°C (SD 1.4), oxygen saturation of 97% (SD 2), heart rate of 113 beats per minute (SD 22), and respiratory rate of 22 breaths per minute (SD 7). Mean laboratory values revealed a white blood cell count of 17,500 cells/μL (SD 9,800) and C-reactive protein of 243 mg/L (SD 144). A higher Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was positively correlated with longer hospital length of stay (r = 0.46, p < 0.01). Conclusion: Despite its morbidity and mortality, iGAS infections often present insidiously with only mild abnormalities in triage vital signs, and require a high index of suspicion by the emergency physician for a prompt diagnosis, particularly in at-risk populations such as patients with diabetes mellitus or those who misuse alcohol or drugs.

Introduction: The goal of palliative care (PC) is to improve quality of life for both patients and families facing a life-limiting illness. Many individuals in need of PC present to the Emergency Department (ED) with symptomatic complaints. Therefore, the ED may be a good place to connect patients with PC teams. Unfortunately, a lack of communication between patients and medical teams may result in admission to hospital even if this no longer aligns with the goals of care. The aims of this study were to identify the proportion of ED patients with unmet PC needs and to determine if access to rapid outpatient PC follow-up could reduce unnecessary admissions. Methods: University Health Network (UHN) is an urban academic centre with EDs at two sites, Toronto General Hospital (TGH) and Toronto Western Hospital (TWH). A consecutively enrolled sample of 417 patients that presented to these EDs between July 1-August 14, 2018 was taken. ED nurses and physicians were asked to complete a content validated PC screening tool on all eligible patients. Patients were eligible for screening if they (1) were >18 years of age, (2) had been designated a level 2-5 according to the Canadian Triage and Acuity Score, and (3) had been triaged to the subacute or acute areas of the department. Results: Across both sites, 45% of patients screened had a life-limiting illness and 30% had unmet PC needs. Among those with unmet PC needs, 79% had no identifiable involvement with a PC team. TWH had fewer patients with a life-limiting illness compared to TGH (31% vs 57%), but higher rates of unmet PC needs (81% vs 59%, confidence interval for the difference: 8%-34%, p = .003) and less PC involvement (6% vs 24%, confidence interval for the difference: 4%-30%, p < .01). 73% of patients at UHN with unmet PC needs were likely to be admitted to hospital. In 14% (n = 17) of these cases, admissions were felt by physicians to have potentially been avoided if rapid PC follow-up was available. Conclusion: A high percentage of patients presenting to the EDs at UHN have life-limiting illnesses with unmet PC needs. A rapid access outpatient PC clinic, available for referral from the ED, may help to both connect patients with the resources they need and avoid admission to hospital.

Introduction: The Community Referral by Emergency Medical Services (CREMS) program was implemented in January 2015 in Southwestern Ontario. The program allows Paramedics interacting with a patient to directly refer those in need of home care support to their local Community Care Access Centre (CCAC) for needs assessment. If indicated, subsequent referrals are made to specific services (e.g. nursing, physiotherapy and geriatrics) by CCAC. Ideally, CREMS connects patients with appropriate, timely care, supporting individual needs. Previous literature has indicated CREMS results in an increase of home care services provided to patients. Methods: The primary objective of this project is to evaluate the impact of the CREMS program on Emergency Department utilization. Data for all CCAC referrals from London-Middlesex EMS was collected for a thirteen month period (February 2015-February 2016). For all patients receiving a new or increased service from CCAC the number of Emergency Department visits 2 years before referral and 2 years after referral were calculated. A related samples Wilcoxon Signed Rank Test was performed to examine the difference in ED visits pre and post referral to CCAC. Results: There were 213 individuals who received a new or increased service during the study timeframe. Median [IQR] patient age was 77 [70-85.5]. 113/213 (53%) of patients were female. The majority of patients 135/213 (63.4%) were a new referral to CCAC. The median [IQR] number of hospital visits before referral was 3 [1-5] and after referral was 2 [0-4]. There was no significant difference in the overall number of ED visits before versus after referral (955 vs 756 visits, p = 0.051). Conclusion: Community based care can improve patient experience and health outcomes. Paramedics are in a unique position to assess patients in their home to determine who might benefit from home care services. CREMS referrals for this patient group showed a trend towards decreased ED visits after referral but the trend was not statistically significant.

Introduction: Cardioactive steroid poisoning occurs worldwide with the use of pharmaceutical digoxin and botanical cardiac glycosides. The wholesale price of the antidote, digoxin immune fab, has increased over 300% from 2010 to 2015. Our objective was to identify gaps in the existing literature with respect to the use of digoxin immune fab in cardioactive steroid toxicity in acute care settings. Methods: We used scoping study methodology, as described by Arksey and O'Malley, to assess the range and scope of empiric research and will report: 1) sources of cardioactive steroid toxicity in acute settings; 2) doses of digoxin immune fab used in treatment; and, 3) intervention outcomes of acute cardioactive steroid toxicity following the administration of digoxin immune fab as first or second-line therapy. We collaborated with a library scientist to devise search strategies for PubMed, CINAHL, EMBASE, CENTRAL and Toxnet. We sought unpublished literature through the Canadian Electronic Library, Proquest, and Scopus and searched reference lists of included studies. We hand searched relevant conference proceedings and applicable guidelines. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data. All discrepancies were resolved through consensus. Results: Our search strategy yielded 3458 results. After screening titles and abstracts 384 underwent full text screening. We included 147 studies and are currently extracting data from 12 French studies and 135 English studies. To date we have extracted data from 90 case reports and case series. Conclusion: Given concerns over rising costs, our findings will shed light on the extent of the evidence for use of digoxin immune fab in acute care settings.

Introduction: Improving public access and training for epinephrine auto-injectors (EAIs) can reduce time to initial treatment in anaphylaxis. Effective use of EAIs by the public requires bystanders to respond in a timely and proficient manner. We wished to examine optimal methods for assessing effective training and skill retention for public use of EAIs, including the use of microskills lists. Methods: In this prospective, stratified randomized study, 154 participants at 15 sites receiving installation of public EAIs were randomized to one of three experimental education interventions: A) didactic poster (POS) teaching; B) poster with video teaching (VID), and C) Poster, video, and simulation training (SIM). Participants were tested by participation in a standardized simulated anaphylaxis scenario at 0-months, immediately following training, and again at follow-up at 3 months. Participants’ responses were videoed and assessed by two blinded raters using microksills checklists. The microskills lists were derived from the best available evidence and interprofessional process mapping using a skills trainer. The interobserver reliability was assessed for each item in a 14 step microskill checklist composed of 3-point and 5-point Likert scale questions around EpiPen use, expressed as Kappa Values. Results: Overall there was poor agreement between the two raters. Being composed or panicked had the highest level of agreement K = 0.7, but a result that did not reach statistical significance (substantial agreement, p = 0.06) calling for EMS support has the second highest level of agreement, K = 0.6 (moderate agreement, p = 0.01), the remainder of the items had very low to moderate agreement with a Kappa value range of -103 to 0.48. Conclusion: Although microskills chesklists have been shown to identify areas where learners and interprofessional teams require deliberate practice, these results support previously published evidence that the use of microskills checklists to assess skills has poor reproducibility. Performance will be further assessed in this study using global rating scales, which have shown higher levels of agreement in other studies.

Introduction: Maintaining competence in high-acuity low-occurrence (HALO) procedures is often difficult due to their infrequent occurrence. While simulation is a valuable tool to hone skills, providing effective simulation-based education (SBE) to learners outside academic centers can be challenging. Utilizing a mobile tele-simulation unit (MTU) with expert instruction from a geographically separated mentor could prove a valuable approach to overcoming barriers in this setting. However, to maximize benefit and buy-in, the training modules developed for this unique delivery method must align with the needs of those practicing in rural settings. Objectives: - To evaluate the procedural skills training needs of emergency medicine (EM) physicians in rural Newfoundland and Labrador (NL) - To inform the development of simulation modules designed for use in a MTU Methods: A web-based needs assessment was distributed to physicians registered with the NL Medical Association, working in rural locations, and having EM listed as their primary specialty. Participants evaluated their comfort, performance frequency and desire to have further training for 12 HALO procedures. Two EM physicians selected these from a broader list of core procedural skill competencies for CCFP-EM residents at Memorial University. Participants were also able to suggest other procedures that might benefit from SBE. Results: The data collection occurred for 8 weeks with a 68% response rate (N = 22). No respondents had formal EM training outside of exposure in family medicine residency. 60% had 10+ years practicing EM. Chest tube insertion (100%), difficult intubation (92.3%) and surgical airway (92.3%) were the procedures that most respondents felt required more SBE. In practice, they most often performed bag-valve ventilation, splint application and procedural sedation (>10 per year). Additional procedures felt to require SBE were central venous line placement and trauma assessment. Opportunities to participate in SBE were limited (66.7%-less than annually). Despite this, most participants agreed SBE would be a significant benefit if accessible (93.3%). The greatest barriers to SBE included lack of equipment, rural location, and time necessary for travel to larger centres. Conclusion: The provision of medical care in rural settings can be particularly challenging when HALO procedures must be performed. Unique delivery methods of SBE targeted to the needs of rural practitioners may help bridge gaps in knowledge and technical skills.

Introduction: Competency-based skills development has driven the evolution of medical education. Simulation-based education is established as an essential tool to supplement clinical encounters and it provides the opportunity for low-stakes practice of common and high-acuity low-occurrence (HALO) procedures and scenarios. This is particularly important for emergency medicine trainees working to build confidence, knowledge, and skills in the field. Methods: In the procedural training sessions, learners rotate through 6 small-group stations over a 3-hour period. Skills topics are determined from faculty input, prior session feedback, and literature reviews. Topics included chest tubes, airway intervention, lumbar punctures and trauma interventions. Online content and brief written materials are used for pre-session learning. The small groups use hands-on faculty-guided training, with real-time feedback. Printed materials supplement key learning points at the stations. A combination of low-fidelity task trainers and simulated patients are used for practice and demonstration. R3 EM residents have the opportunity to mentor junior learners. Brief participant surveys are distributed at each session to gather qualitative and quantitative feedback. Results: Feedback forms were completed by 79/85 (92.9%) learners over a period of 4 years (2015-2018). Participants included medical students (11.8%), EM residents (52.9%), and non-EM residents (35.3%). 84.8% (67/79) gave positive qualitative feedback on the sessions, citing points such as the beneficial practice opportunities, quality of instruction, and utility of the models. Updated surveys (N = 26) used a 5-point Likert scale (1 = disagree strongly; 5 strongly agree) in addition to qualitative feedback. Participants indicated that sessions were valuable, and informative (M = 4.692, SD = 0.462; M = 4.270, SD = 0.710). They reported increased understanding of procedures discussed, and they were likely to recommend the session (M = 4.301, SD = 0.606; M = 4.808, SD = 0.394). Conclusion: The ongoing evaluation of our mentor guided hands-on low-fidelity and hybrid simulation-based procedural skills sessions facilitates meaningful programmatic changes to best meet the needs of EM learners. Sessions also provide a forum for EM resident mentorship of junior learners. Feedback indicates learners enjoyed the sessions and found this to be an engaging and effective instructional modality.

Introduction: Inter-disciplinary interaction in the Emergency Department (ED) is critical for good patient care. The perception of paramedics’ experience in this interaction is not well described in the literature. This project gives voice to paramedics’ understanding of their role in the ED. Methods: Qualitative thematic framework analysis of digitally recorded, semi-structured, telephone interviews of 11 paramedics from one urban and one rural Paramedic Service in southwestern Ontario. Recordings and field notes were repeatedly reviewed and discussed by two researchers. A conceptual framework was constructed from themes emerging from the data. Results: Paramedics interviewed had 7-33 years of primary, advanced, or critical care experience. Three major themes emerged. (1) Patient advocate – Paramedics present the patient pre-hospital context and course of care information. They feel this information is essential and must be communicated. (2) Communication – Concerns raised that information is not listened to and valuable information is lost or ignored. A formal 30-second ‘pause’ for a structured paramedic to ED staff handover was seen as beneficial. Paramedics also want clinical feedback and outcome information from ED staff. No formal mechanism exists to obtain this. (3) Respect – When it exists, it is often based upon personal relationships between individuals. Paramedics feel when ED staff don't understand their scope of practice, their skills and abilities are ignored. In smaller EDs, paramedics also see themselves as a resource to help the ED staff with technical procedures. They need respect to do this. Conclusion: Paramedics’ perceive themselves as providing valuable information and advocacy for their patients in the Emergency Department. In order to present this information, they require uninterrupted time, as short as 30-seconds, for communication. Their relationship with the ED staff is further strengthened by mutual respect and understanding of each discipline's scope of practice and interdisciplinary teamwork. Paramedics would like more feedback on clinical outcomes and on their pre-hospital care. Some areas for practice change suggested by this study include: time for un-interrupted communication of pre-hospital information, formal feedback, and reflection on how to improve interdisciplinary interactions.

Introduction: Learners, ether medical students or residents, often provide the initial assessment of patients visiting the Emergency Department (ED). Their involvement in ED patient care has been shown to increase length of stay, time to disposition decision, utilization of imaging and admission rates. It is unclear, however, if learners have an impact on the rate of short-term unscheduled return visits. The objective of this study was to determine if the involvement of learners in ED visits increases the rate of short-term unscheduled return visits. Methods: This study was a retrospective analysis of ED visit data at a single tertiary care center over a one-year period. Short-term unscheduled return visits (return visits) were defined as ED visits presenting within 72 hours of discharge from an initial non-admit ED visit and resulting in an admission to an inpatient unit on the second visit. The primary outcome was the rate of return visits for each staff physician, with and without learners involved during the initial visit. The secondary outcome assessed the interaction of level of training (medical student year 3, 4, resident year 1, 2, etc.) on return visit rates. For the primary outcome, statistical analysis was with a Wilcoxon Matched Pairs test; staff alone vs with learners. A Kruskal-Wallis test was used to compare learner level of training. Results: Return visits accounted for 1858 (1.09%) of all visits (N = 172494) to this tertiary care ED over the one-year study period. Return visits were statistically more likely when learners were involved in the initial ED visit (1.16%, CI 0.12), compared to initial visits seen by staff physicians alone (0.88%, CI 0.09) (p < 0.0001). Return rates were statistically higher for PGY2 (1.67% CI 0.35) and PGY3 (1.66% CI 0.28) residents compared to staff physicians alone (p < 0.0001). There was no difference in return visit rates between staff physicians and third year medical students (1.07% CI 0.27), fourth year medical students (1.21% CI 0.37), PGY1 (1.42% CI 0.22), PGY4 (1.23% CI 0.54) or PGY5 (1.33% CI 0.49) residents. Conclusion: This study demonstrated that the involvement of learners in ED patient assessments increased the rate of short-term unscheduled return visits. Moreover, return visit rates were highest for PGY2 and PGY3 residents. Further work is needed to understand the factors that contribute to this phenomenon.

Introduction: Our principal aim was to document the feasibility of the systematic measurement of the inter-arm blood pressure difference (IABPD) during an episode of transient ischemic attack (TIA) or mild stroke diagnosed in the Emergency Department (ED). As secondary goal was to compare the systolic blood pressure (BP) at triage with the systolic BPs measured during the IABPD. Methods: This is a single center pilot study. Patients presenting in the ED for a diagnosis of TIA were recruited. Once patient has been triaged and diagnosed of TIA, a research assistant made sure that the patient lay on a stretcher for at least 5 minutes. Two automated sphygmomanometers were applied, on each arm. No specific device or device calibration were required. Three consecutive simultaneous BP readings were performed, inverting cuffs arm to arm between each reading. Only the last two set of readings were used to calculate the mean IABPD. This method enables to minimize the error coming from the potential sphygmomanometers’ inaccuracies. Results: 32 patients were recruited from June to September 2017 and all had a successful IABPD measurement. Four patients had an IABPD >10 mmHg, varying from 1.5 to 13 mmHg when the left arm was higher and from 1 to 61 mmHg when the right arm was higher. Of the 22 patients where the triage BP arm side selection was recorded, only 11 were congruent with the arm presenting the highest BP during the IABPD measurement. Selecting of the arm with the highest BP value may better reflect cerebrovascular risk exposition. The mean systolic BP at triage was 159.3 mmHg (95%CI: 144.9-173.7) compared to144.8 mmHg (95%CI: 132.9-156.7) if the arm with the highest value during the IABPD measurement is selected and 142.4 mmHg (95%CI: 130.8-154.0) if the same arm as triage is selected. The p-value for these differences were 0.003 and 0.001 respectively. The patient which presented the IABPD of 61 mmHg, had a stroke 3 days after its ED visit which subsequently led to her death 10 days later. Conclusion: Our results show that the systematic IABPD measurement using a pragmatic approach in the ED is feasible and is ready to investigate its use in the context of a new TIA or mild stroke. This information may contribute to a better discrimination of the short-term risk of stroke and may help to diagnose acute aortic dissection, monitor more accurately BP during hyperacute stroke or estimate intracerebral hemorrhage risk if systemic thrombolysis is considered.

Introduction: It was demonstrated that the early trauma team activation (TTA) could improve younger trauma patients outcomes and mortality rates. However, the link between older patient prognosis improvement and the activation / effectiveness of the Trauma team (TT) is still unclear. There is also a lack of information about the exact and optimal structure of TTs and their activation criteria, which may differ across centers. The main objective of this study is to provide a description of the current TT available in level 1 and 2 centres across Canada. Methods: In 2017, a survey using a modified Dillman technique was sent to 210 health professionals scattered across all Canadian trauma care facilities. The survey included questions regarding 1) the presence and the composition of a TT, 2) the established TT activation criteria, and finally 3) the initial patient care. Results: A total of 107 (57%) completed surveys were received. Among them, only 22 (11.7%) were from level 1 or 2 centres and were therefore considered for analyses. Seventeen respondents had a TT in their centre, and they all shared their TT activation criteria (1 to 27 different indications). Most frequently mentioned criteria were: suspected injuries (58.8%), judgment of the emergency physician (41.2%), systolic blood pressure (47.1%), Glasgow Coma score (35.3%) and respiratory rate (28%). In presence of a prehospital care warning trauma, the initial assessment of a severely injured patient is exclusively completed by a member of the TT for only 35.1% of the respondents. For 11.8% of respondents, TT coordinates airway management. For 64.7% of participants, the TT leader is the dedicated care provider to accompany patients until final orientation. Conclusion: These results suggest a great variability across Canada regarding the roles assumed by the TT, but also regarding the activation criteria leading them to take action.

Introduction: Delirium is a common complication among older people who need care in the emergency department (ED). Mobility is an evidence-based non-pharmacologic strategy shown to reduce delirium and functional decline among older patients in the acute care setting. However, previous research has shown that compliance with mobility is important to achieve this decreased incidence of delirium. Gait tracking devices have been used in previous studies to accurately measure steps, engagement and intensity of physical activity in older hospitalized patients.The objectives of this study are to compare the feasibility and validate the accuracy of three accelerometer-based gait tracking devices. This is the first step in a program of research to objectively measure mobility among older ED patients as a potential marker of delirium risk. Methods: This is a prospective, observational study of patients 65 years of age and older during their ED visit. We excluded those with critical illness, unable to communicate or provide consent (language barrier, aphasia); and those with any ambulatory impediments. Consenting participants wear the gait trackers for the duration of their stay or for a minimum of 8 hour, and ambulate as normally as they would in their home. Devices were retrieved when the patient was admitted, discharged or, after 8 hours and the steps count was then recorded from an online interface. Our primary feasibility measure is the proportion of eligible patient for which we are be able to recover the tracker and record their steps. The primary validation endpoint will be the concordance between steps recorded by the gait tracking device compared to a gold standard manual step count over a fixed distance. We will report proportions with exact binomial 95% confidence intervals (CI) for feasibility and validity endpoints. Results: Preliminary data from an initial pilot phase includes 7 participants who wore a gait tracking device during their ED visit. Mean age was 79.7 years (+/−5.76) and 57% were females. Devices were worn by participants and recovered by research staff in all 7 cases (100%, 95% CI: 59 – 100). Data from online interface has been collected from 6 participants (85%, 95%CI: 42 – 99). Mean step count by observer was 86.17 +/− 4 (95% CI 82.2 – 90.2) and 70.3 +/− 4 (95%CI 66-74.3) by gait tracker. Conclusion: Our preliminary data suggests that use of gait-tracking devices in the ED is feasible.

Background: Patients presenting to the Emergency Department (ED) with unmet palliative care needs are often admitted to hospital and this can be a pivotal point in their subsequent health care journey. Literature from the United States supports the integration of palliative care resources in the ED and to our knowledge, this has yet to be done in a Canadian setting. Aim Statement: To develop, implement, and evaluate a model to support patients presenting to the ED with unmet palliative care needs. Measures & Design: A pilot project was implemented in one campus of the ED at a tertiary care academic center in Ottawa, Ontario. A palliative care nurse specialist was available for consultation with goals to: a) reduce admission to hospital for patients choosing to have a palliative approach to their care; b) increase coordination between ED and community resources; and c) be a resource for ED staff. Referral criteria were developed after systematic review of the literature and in consultation with palliative and emergency medicine experts. Evaluation/Results: Over the course of the study period (9 months), 50 referrals were made. The primary reason for referral was for increased community supports. Patient outcomes: 10 patients were discharged to hospice/palliative care units from the ED, 38 patients were discharged home. Of those discharged home, 66% had no returns to ED within 30 days. Qualitative feedback collected via pre and post survey has been extremely supportive from ED health care practitioners and community palliative care providers. Discussion/Impact: This ongoing project has led to positive, patient centered outcomes and decreased admission to acute care hospital. Ongoing evaluation will include consideration of Ontario Palliative Care Network quality indicators and cost-analysis to determine impact on health care system.

Introduction: Canadian post-secondary campuses are densely-populated communities and the first home-away-from-home to many students participating in various academic programs, new social activities, and on-campus athletic activities. The diversity of on-campus activities combined with the high-stress of academic programs results in illness and injury rates that may increase the strain on emergency medical systems. Existing on some campuses for more than 30 years, campus emergency medical response teams (CEMRTs) address the need for a local emergency medical service that can provide first-aid in low-acuity situations and rapid response to high-acuity emergencies. In Canada, many student-run volunteer-responder CEMRTs exist but the range of their service capabilities, operations, and their call-volumes have not been described previously. This study aims to fill this knowledge gap. Methods: We surveyed the 30 known campus emergency medical response teams identified through membership in the Canadian Association of Campus Emergency Response Teams. The 32-question survey asked information on their level of training (standard first aid [SFA], first responder [FR], emergency medical responder [EMR]), service operations including call volume, and funding model. This study was approved by the Western University Institutional Review Board. Results: Twenty-four teams completed the survey (80%); the majority of which are located in Ontario (70%, 16 teams). One team reported that they are no longer in operation. Eleven teams (48%) have medical directors. Nine teams (39%) reported responding to ≤100 calls/year, 11 teams (48%) reported 100-500 calls/year, and 3 teams (13%) reported >500 calls/year. Responders of two teams (9%) maintain training at SFA level; 14 teams (61%) have some or all responders with FR training; and 6 teams (26%) have some or all members certified at EMR level. Twenty-one teams (91%) are equipped with AEDs and 19 teams (83%) are equipped with oxygen. Common medications carried include epinephrine (13 teams, 57%), naloxone (12 teams, 52%), and acetylsalicylic acid (9 teams, 39%). Conclusion: Canadian post-secondary campuses have highly-active student-run volunteer CMERTs. Considerable variability in the services provided may reflect the unique needs of the campuses they serve. CEMRTs may reduce low-acuity case demand on local emergency medical response and emergency department services in some communities; their impact on system demand and costs is the subject of future work.