Introduction: During the one-year CCFP-EM program, residents rotate through different teaching sites. The purpose of this project is to investigate differences in procedural skills acquisition between these sites, which will help identify the effectiveness of each setting for teaching procedural skills amongst EM trainees. Methods: Over a two year period, residents enrolled in a CCFP-EM residency training program were asked to log their procedures and the sites where they were performed. The cumulative data was analyzed to show the number and types of procedures performed at each site. Results: A total of 477 procedures were logged over two years, with 198 procedures performed at urban tertiary emergency departments (EDs), 116 at community EDs, 87 at intensive care units (ICUs), 37 at urgent care centre, 24 in clinics, and 15 at other settings. Overall, 48 point of care ultrasounds, 75 vascular access procedures, 99 reduction/casting, 48 lumbar punctures, 29 procedural sedations, 125 minor surgical procedures, and 32 other procedures were performed. The majority of procedures were performed at the tertiary care urban ED, followed closely by community ED setting. The only exception was vascular access, which was performed most commonly in ICU settings. Conclusion: Our urban tertiary care ED setting provided the most learning opportunity for procedural skill acquisition, suggesting that having maximized time allocated in this setting is essential for EM learners to acquire procedural skills. One exception is that EM learners gain more vascular access training in ICUs.

Introduction: Pulse oximetry is a standard component of Emergency Department (ED) patient monitoring. Pulse oximetry measures peripheral capillary oxygen saturation (SpO2) levels and can be used to monitor cardiorespiratory conditions. The normal SpO2 level for adults is approximately 96%. Oxygen saturations of <92% are considered problematic and levels <90% may indicate cardiorespiratory disease. However, low oxygen saturations are often seen in elderly patients with comorbidities. This research investigated the significance of hypoxia in asymptomatic older ED patients with no apparent acute illness. Methods: ED patients >75 years with a documented room air pulse oximetry reading <92% were eligible. Exclusion criteria included dyspnea, chest pain, SBP <100mmHg, HR >120 or <50; sustained tachypnea (RR > 20); acute cardiopulmonary conditions, delirium or acutely altered mentation. Eligible patients were separated into two groups: 1) Sustained hypoxia: two or more SpO2 readings <92% 2) Unsustained hypoxia: one SpO2 reading <92%. 30-day adverse events were tracked using a Sunrise Emergency Care record review. Adverse outcomes investigated included death, MI, CHF, PE, cardioversion, ICU admission, intubation, ED revisit or re-hospitalization. Patient characteristics studied were age, sex, arrival mode, triage complaint, CTAS level, pulse, BP, RR, weight, residence (independent, assisted living, facility), comorbidities, PHN, referral, disposition, and test results (CXR, troponin, ECG, CT). Follow-up phone calls were completed after 30 days to assess patient status and confirm ED revisit. Results: A total of 876 ED patients >75 years were screened and 30-day follow-up data was analyzed for 34 enrolled patients. The sustained hypoxia group (n = 23) showed higher rates of 30-day adverse outcomes of death, ED re-visitation, MI, CHF, a severe episode of COPD, PE and ICU stays compared to the unsustained hypoxia group (n = 11). Administrative data of 31,095 patients >75 years from four Calgary EDs in 2017 was also analyzed and 7,771 (20%) were hypoxic at triage (SpO2 <92%). Adverse outcomes and mortality were significant in discharged hypoxic patients (especially if SpO2 <90%). Conclusion: ED re-visits, cardiorespiratory complications, and mortality were significant in discharged sustained hypoxic patients, especially if O2 sat <90%. Pulse oximetry assessment of oxygen saturation in seniors’ care facilities and physicians’ offices may be important in screening for future adverse health outcomes in elderly patients.

Introduction: Renal colic is a common presentation which exerts a significant burden on healthcare infrastructure. A significant proportion of patients managed with observation may return to the Emergency Department (ED) prior to spontaneous passage due to inadequate analgesia. It is unclear whether early urologist consultation would limit the burden of renal stones by reducing returns to the ED. We wished to determine whether urologist referral from the ED department is associated with fewer returns to the ED with renal colic. Methods: We conducted a retrospective chart review using RECORD methodology of consecutive patients diagnosed with CT-confirmed, ureteric or renal calculi in our ED over a two-year period. Disposition was categorized as either hospital admission, outpatient urologist referral, follow up with primary care, or no follow up. The primary outcome was the 30-day ED re-presentation for renal colic. Multivariate logistic regression was used to identify predictors for ED-return. Results: In total, 232 patients met our inclusion criteria. Urgent or outpatient urologist referral was not associated with a significantly lower ED return rate when compared to patients with no follow-up. Surprisingly, urologic intervention and stent placement were both independent predictors for ED return (OR: 2.03; 95% CI: (1.06-3.88); p:0.03) and (OR:2.08; 95% CI: (1.07-4.05). Conclusion: A significant proportion of patients who underwent urologist-led intervention returned to the ED with renal colic. Further study may help clarify the role of early urologist referral for renal calculi, as this may not reduce ED return rates when compared to conservative management.

Introduction: Mental health and addiction presentations are on the increase in Canadian Emergency Departments (EDs) and are placing strains on existing resources. The purpose of this study is to examine practice variations and opportunities for improved mental health (MH) consultation practices across four adult EDs. Methods: We conducted a retrospective analysis of administrative data from Alberta Health Services (AHS) at urban Calgary Zone EDs from 2015 to 2018 regarding MH consults requested and patients admitted to inpatient psych. Individual MD and overall referral rates as well as admission rates for patients consulted to MH were considered. Time of day and patient ETOH level were also examined as potential influencing factors. CEDIS codes were used to identify MH complaints. Results: 73,536 MH related visits were included, 29,228 received a MH consult with 10,648 admitted to an inpatient MH unit (36.4%). The admission rate among consults requested varied considerably among the 200 MDs who evaluated more than 50 patients with MH complaints; median 35.9%, IQR – 25.0 to 47.5. The average consultation rate for ETOH positive patients was 28.4% median 26.35%, IQR – 21.2 to 35.0% During regular working hours (08:00-17:00), there were 33,599 MH visits, 15,035 received a psych consult with 5,976 admitted to an inpatient MH unit. The admission rate among consults was 39.8%. For the remaining hours(17:01-07:59) there were 39,939 MH visits, 14,191 received a psych consult with 4,672 admitted to an inpatient MH unit. The admission rate among consults was 32.9%. Conclusion: Varying MD thresholds for MH consultation are reflected in a wide range of admission rates among patients consulted for MH evaluation in the ED. ETOH and timing of presentation are factors which modulate the likelihood of admission. There may be opportunities to improve MH referrals from the ED by providing consultation feedback to providers.

Introduction: While boarding of patients in the emergency department (ED) has been well documented and is carefully monitored, the time spent in emergency beds by patients waiting for Adult Protection (AP) placement is often relatively unnoticed, as they are not flagged as ‘admitted’. These patients have no emergency needs, yet consume considerable ED resources, often in excess of patients requiring emergency care. Staff familiarity with this issue may also bias them to premature diagnostic closure of patients as ‘placement problems’, risking misdiagnosis of active medical conditions. An observational study to retrospectively quantify the time spent in the ED by patients referred to AP services for urgent placement from the ED. Methods: A three-year audit of ED social work records of patients referred for AP. Results: For the period of October 1 2015-September 30, 2018, the ED social work service kept records of patients referred for AP from the ED. During this period, a total of 142 patients were referred to AP (40, 50, and 52 in each year respectively). There was an increase of 10 patients between 2015/16 and 2016/17 and two patients from 2016/17 to 2017/18. The overall length of stay for this subset of ED patients during this three-year period was alarmingly high, with an average length of stay of four days per patient (range 2.7 hours-18.5 days) compared to an average of all patients of 4.9 hours and admitted patients of 13.6 hours. Conclusion: Patients in the ED who are referred to AP services consume considerable ED resources, often requiring complete medical work-up, capacity assessments and close monitoring by multiple emergency personnel. This has been reported to cause considerable stress and friction between staff and consulting services. Furthermore, these patients are poorly served in a hectic, brightly lit, and noisy environment. The impact is often not fully appreciated due to ineffective capture by patient tracking systems.

Introduction: Patients with end-stage conditions require integrated physical, spiritual, psychological and social care. Despite efforts to provide comprehensive community care, those with severe symptoms often present to emergency departments (EDs) with palliative care (PC) needs. The objective of this study was to identify patients with end-stage diagnoses presenting to EDs, and to document and compare their PC needs. Methods: A four-month prospective cohort study was conducted in two Canadian EDs. Using a modified PC screening tool, volunteer emergency physicians identified adult patients with end-stage illnesses and documented their PC needs. This tool has the ability to classify patients as having met vs. unmet PC needs based on the documentation of risk factors. Research assistants documented demographic information, severity at presentation (Canadian Triage and Acuity Scale {CTAS}), disposition and revisits from an electronic repository. Bivariate comparisons between patients with met vs. unmet PC needs were completed. Results: Overall, 663 patients were enrolled, of which 78% (n = 518/663) were identified as having unmet PC needs according to the screening tool. Cancer was the most prevalent condition in each group (43% unmet needs, 37% met needs). There was no significant difference between the two groups in terms of age, sex or CTAS score. The unmet PC needs group was more likely to be admitted (68% vs. 50%; p = 0.0001) when compared to patients with PC needs assessed as being met. No significant difference was noted in terms of time to physician assessment or ED length of stay. The two groups did not significantly differ in the proportion of return visits within 30 days (34% vs. 32%) or the average number of return visits (3 vs. 2 visits). A higher proportion of patients with unmet PC needs made at least one visit to the ED in the 6 months prior to their index visit compared to patients with met PC needs (74% vs. 51%, p < 0.001); yet, the average number of ED visits was similar between the groups (3 visits). Conclusion: This study revealed that patients with end-stage diagnoses, especially cancer, commonly have unmet PC needs. They are also more likely to present to the ED and to require hospitalization than patients in whom PC needs have been met. Further investigations into their clinical profile and health care utilization may clarify the impact of their unmet PC needs on the healthcare system.

Introduction: While consultation is a common and important aspect of emergency department (ED) care, a previous systematic review identified significant utilization and process variation across ED's. The aim of this review update was to examine the proportion of the patients undergoing consultation in the ED among recent studies. Methods: Eight primary literature databases and the grey literature were searched. Studies published from 2007 to 2018 focusing on all-comers to the ED and reporting a consultation-related outcome were included. Disease- and specialty-specific studies were not eligible. Two independent reviewers screened studies for relevance, inclusion, quality assessment, and data extraction. Disagreements were resolved through consensus. Means, medians and interquartile ranges are reported. Wilcoxon-rank sum test and one-way ANOVA were used to identify differences between groups, as appropriate. Results: A total of 2632 unique citations and 49 studies from the grey literature were screened, of which 29 primary studies were included. Fifteen studies reported on the proportion of ED patients undergoing consultation, involving EDs in the Middle East (n = 4), North America (n = 4), Asia (n = 4), and Europe (n = 3). Overall, the proportion of patients receiving consultation ranged from 7% to 78% (median: 26%; IQR: 20%, 38%). There were no differences in the proportions of consulted patients based on country of origin. Ten studies were conducted prior to 2013, while five studies recruited patients during and after 2013. The mean proportion of consulted patients was lower for post-2012 studies compared to pre-2012 studies (mean: 18% vs. 36%; p = 0.0048). The proportion of consulted patients admitted to hospital ranged considerably between the 14 reporting studies (median: 56%; IQR: 49%, 76%). No differences in the proportion of admitted patients undergoing a consult were identified based on country of origin or year of recruitment for the study. Conclusion: Although consultation utilization appears to be decreasing overall, there is considerable practice variation in EDs around the world. These differences may result from variation in patient acuity, case-load, staffing levels, institutional and health-system organization, and medical training and future research should explore reasons for these differences.

Introduction: Renal colic is one of the most common presentations to the emergency department (ED), and often requires complex interdisciplinary collaboration between emergency physicians and urology surgeons. Previous literature has shown that adoption of interdisciplinary rapid referral clinics can improve both timeliness of care and patient outcomes. However, these Acute Care Surgery models have not yet been commonly adopted for urology care in the ED. Methods: In July 2016, we adopted the intervention of an Acute Care Urology (ACU) model through the creation of a rapid referral clinic dedicated to ED patient referrals, the addition of an ACU surgeon, and enhanced use of daytime OR blocks. We conducted a manual chart review of 579 patients presenting to the ED with a complaint of renal colic. Patient data was collected in two separate time periods to analyze trends before implementation of the ACU model (pre-intervention, September - November 2015), to examine the model's impact (post-intervention, September - November 2016). Secondary methods of evaluation included a survey of 20 ED physicians to capture subjective feedback through Likert scale data. Results: Of the evaluated 579 patients with a complaint of renal colic,194 patients were discharged from ED with an diagnosis of obstructing kidney stone and were referred to urology for outpatient care. The ED-to-clinic time was significantly lower for those in the ACU model (p <0.001). The mean time to clinic was 15.76 days (SD = 15.47, range 1-93) pre-intervention versus 4.17 days (SD = 2.33, range = 1-12) post-intervention. Furthermore, the ACU clinic allowed significantly more patients to be referred for outpatient care (p = 0.0004). There was also higher likelihood that patients would successfully obtain an appointment following referral (p = 0.0055). Decreasing trends were shown in mean ED wait time, in addition to time from assessment to procedure. Results of the qualitative survey were overwhelmingly positive. All 20 surveyed ED physicians were more confident that outpatients would be seen in a timely manner (85% strongly agree, 15% agree). Qualitative feedback included the belief that follow-up is more accessible, that ED physicians are less likely to page the on-call urologist, and that they are able to discharge patients sooner. Conclusion: The ACU model for patients with renal colic may be beneficial in reducing ED-to-clinic time, ensuring proper follow-up after ED diagnosis, and improving patient care within the ED.

Introduction: Benign headache (BHA) management varies across emergency departments (EDs). This study documented current BHA management by Alberta emergency physicians (EP) in order to develop a provincial intervention to improve standardized practice. Methods: A convenience sample of Alberta EPs completed an online survey exploring their ED BHA management practices. Results are expressed as proportions. Results: A total of 73 EPs (73/192; 38%) who were mostly male (63%) and practiced emergency medicine for at least 15 years (51%) responded. EPs reported routine ED orders for metoclopramide (97%), ketorolac (90%) and IV fluids (85%) for patients with BHA showing no signs of pathological headache. For moderate-severe BHA's that did not improve with routine treatment, preferences were: IV narcotic (58%), IV dexamethasone (44%), and IV/IM dihydroergotamine (27%). Typically, EPs reported not ordering investigations for moderate-severe BHA presentations (88%); however, for those not improving the most common investigation was computed tomography (CT; 47%). CT ordering was associated with the following clinical scenarios: 1) not responding to traditional therapy and consulted to specialist (64%); 2) not responding to traditional therapy and being admitted (64%); 3) first presentation and afebrile (19%); 4) severe pain (11%); and 5) responding to traditional therapy and febrile (11%). One-quarter of EPs (27%) believed their patients usually or frequently expected a CT. Most EPs (60%) reported being completely or mostly comfortable discussing CT risks. Only 44% reported always or usually discussing risks prior to ordering. EPs reported that they were most frequently prevented from discussing risks because the patient was critically ill (42%) or because they believed explaining risks would not alter patient expectations (21%). These concerns were mirrored in the barriers EPs anticipated to limiting imaging, specifically the fear of missing a severe condition (62%), and patient expectation/request for imaging (48%). Conclusion: Self-reported treatment preferences for uncomplicated BHAs appear to be relatively consistent. Chart reviews could help assessing the reliability of self-reported BHA management practices. Perceived patient expectation appears to be an important influence on EP imaging ordering. Studies examining the communication between EPs and their patients are needed to explore how these expectations and perceived expectations are negotiated in the ED.

Introduction: Efforts to engage patients in research when presenting to emergency departments (EDs) have explored the utility of online tools; for example, through QR-based applications. It is unclear whether these are effective strategies for engaging patients in research activities while saving costs of in-person surveys. This study evaluated whether patients would participate in QR codes or short URL-linked surveys available in EDs across Alberta. Methods: A patient waiting room poster was developed as part of a stepped-wedge randomized controlled trial. The waiting room poster was introduced in 15 urban and regional Alberta EDs with a median annual volume of approximately 60,000. A QR-code and short URL were placed on the poster inviting patients to participate in an online survey and evaluate the poster's usefulness and acceptability. Additionally, written discharge instructions, which were part of the intervention materials, were distributed with QR-code and short URL link to surveys for patients to share their ED care experience. Patients were not prompted by any staff or research personnel to encourage use of the QR codes or the short URLs; however, a survey was conducted with ED waiting room patients in 3 urban EDs to ascertain whether they had downloaded a QR reader on their devices and the frequency of use of these applications. Results: Given the stepped-wedge nature of the study, these materials were available for a total of approximately 123 months (3 sites for 13 months, 4 sites for 10 months, 4 sites for 7 months, and 4 sites for 4 months). Over the study period, 15 patients accessed and completed the online survey linked to the QR code or the short URL placed on the posters. No patients completed the online surveys linked to the QR code or the short URL placed on the discharge instructions. The in-person survey conducted within the ED waiting room identified that 34% of respondents had a QR code reader downloaded on their phone (108/316). Of those with a QR reader, 33% reported using the reader at least once within the last 6 months. Conclusion: In this study, few patients downloaded QR readers on their electronic devices while in the ED waiting room. Without prompting, this appears to be an ineffective strategy for engaging patients in emergency medicine research. Other engagement strategies optimizing human resource investment are urgently needed to effectively conduct research in EDs.

Introduction: Variation in image ordering exists across Alberta emergency departments (EDs). Evidence-based, pocket-sized knowledge dissemination tools were developed for two conditions (acute asthma [AA] and benign headache [BHA]) for which imaging (chest x-ray [CXR] and computed tomography [CT], respectively) has limited utility. This study explored tool acceptability among ED patients and emergency physicians (EPs). Methods: Tool feedback was provided by EPs, via online survey, and adult patients with AA and BHA via in-person survey. EPs qualitative interviews further explored communication tools. Preliminary descriptive analyses of survey responses and content analysis of interview data were conducted. Results: Overall, 55 EPs (55/192; 29%) and 38 consecutive patients participated in the AA study; 73 EPs (73/192; 38%) and 160 patients participated in the BHA study. In both studies, approximately 50% of EPs felt comfortable using the tool; however, they suggested including radiation risk details and imaging indications and removing references to imaging variation and health system cost. In the BHA study, EPs opposed the four Choosing Wisely® campaign questions fearing they would increase imaging expectations. In both conditions, most patients ( >90%) understood the content and 68% felt the information applied to them. Less than half (AA:45%; BHA: 38%) agreed that they now knew more about when a patient should have imaging workup done. Following tool review, 71% of AA and 50% of BHA patients stated they would discuss their imaging needs with their ED care provider today or during a future presentation. Both patient groups suggested including: additional imaging details (i.e., indications, risk, clinical utility), removing imaging overuse references, and including instructions that encourage patients to ask their EP questions. EP interviews (n = 12) identified preferences for personalized and interactive tools. Tensions were perceived around ED time pressure as well as remuneration schemes that fail to prioritize patient conversation. Tool centralization, easy access, and connection with outpatient support were also key themes. Conclusion: Both patients and EPs provided valuable information on how to improve ED knowledge dissemination tools, using two chronic conditions to demonstrate how these changes would improve tool utility. Implementing these recommendations, and considering preferences of EPs and patients, may improve future tool uptake and impact.

Introduction: Quality improvement and patient safety (QIPS) activities in healthcare have become increasingly important, but it is unclear what the current national landscape is with regards to how individual EM departments are supporting QIPS activities and evaluating their success and sustainability. We sought to assess how Canadian medical school EM departments/divisions and major Canadian teaching hospitals approach QIPS programs and efforts, with regards to training, available infrastructure, education, scholarly activities, and perceived needs. Methods: We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee, including a)formal training/skill capacity; b)operational infrastructure; c)educational activities; d)academic and scholarship, and e)perceived gaps and needs. Surveys were pilot-tested and revised by authors. “Survey 1” (21 questions) was sent by email to all 17 Canadian medical school affiliated EM Department Chairs and Academic Hospitals Department Chiefs; “Survey 2” (33 questions) to 11 identified local QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey. We present descriptive statistics including proportions, means, medians and ranges where appropriate. Results: 22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. 45% of respondents described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per center ranging from 1-10 over the past 5 years. A minority of participants reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%). Conclusion: This environmental scan provides a snapshot of QIPS activities in EM across academic centers in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.

Introduction: Endotracheal intubation (EI) is frequently performed in the emergency department (ED). Although this procedure is generally life-saving, EI is also known to cause adverse effects, such as hemodynamic alterations. A systolic blood pressure <90 mmHg is the most commonly accepted definition of hypotension; however systolic blood pressure naturally increases with age. The National Trauma Triage Protocol now states that this threshold could be raised to 110 mmHg in older patients. Objective: to determine the impact of increasing the post-intubation hypotension (PIH) threshold to 110 mmHg on hospital length of stay and mortality in older patients. Methods: Design: A historical cohort of patients admitted in a level-1 trauma center ED between 06/2011 and 05/2016 was constituted. Population: Patients were included if pre-EI vital signs were available, their intubation was performed in the resuscitation room, were aged ≥65, if no surgical access was needed and if EI was performed in ≤3 attempts. Measures: All clinical data including vitals were prospectively recorded using the software ReaScribe. Main outcome was in-hospital mortality. Analyses: Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: A total of 181 patients were included. When using the 90-mmHg threshold, 92 patients suffered from PIH. Mean length of stay for these PIH patients was 18.9 days, compared to 12.0 days for non-hypotensive patients (P = 0.06). Mortality rate at 24 hours was 9.78% and 15.83% for PIH and non PIH patients, respectively (p = 0.2). The 110-mmHg threshold identified 33 additional PIH patients (n = 125) and their mean length of stay was 17.8 compared to 10.2 days for non PIH patients (P = 0.02). Mortality rate at 24 hours was 9.90% for PIH patients and 21.43% for non PIH patients (p = 0.02). Conclusion: PIH was associated with a significant increase in LOS when the PIH threshold is set at 110. Mortality rate is high in the intubated ED older patient and that increasing hypotension threshold for older patient seem to have no impact on patient mortality at 24 hours. Since our sample is limited, more research is needed to confirm these results.

Introduction: Hypotension is known to severely impact the prognosis of patients in need of acute care. Endotracheal intubation (EI) is a procedure that is often used in the emergency room for patients with severe conditions. Post-intubation hypotension (PHI) is a well-known adverse effect of EI, although the impact of PHI on mortality is still unclear. The objective of this study was therefore to evaluate the association between post-intubation hypotension (PIH) and in-hospital mortality rates and length of stay (LOS). Methods: Design: A historical cohort of patients admitted in a university-affiliated emergency department (ED) between 06/2011 and 05/2016 was constituted. Population: Patients aged ≥16 were included if pre-EI vital signs were available, if their intubation was performed in the resuscitation room, if no surgical access was needed and if EI was performed in ≤3 attempts. Measures: All clinical data including vitals were prospectively recorded using the software ReaScribe. Hypotension was defined as a systolic blood pressure ≤90 mmHg. The occurrence of PIH was assessed at 5, 15, 30 minutes and any time after intubation. Main outcomes were in-hospital mortality and hospital length of stay. Analyses: Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: A total of 497 patients were included in our analyses. Of these patients, 63 (12.7%) suffered from PIH at 5 minutes, 120 (24,1%) at 15 minutes, 168 (33,8%) at 30 minutes and 209 (42%) at any moment after intubation. Mortality rates were 42.9% (n = 27), 35.8% (n = 43), 33.9% (n = 57) and 30.6%(n = 64) for patients who presented PIH at the 4 time periods, respectively, while 26.74% patients died in the normotensive group. PIH at 5 (p = 0.006), 15 (p = 0.04) and 30 minutes (p = 0.05) was associated with a significant increase in overall post-intubation mortality. Mean LOS for patients who suffered from PIH was 16.7, 18.9, 17.3, 17.4 days compared to 19.5 (p = 0.22) days for the normotensive group. Conclusion: Early post-intubation hypotension at 5 minutes was strongly associated with an increased mortality. As for the in-hospital length of stay, PIH was not associated with an increased LOS. Our results show that PIH within 30 minutes of intubation is associated with an increased mortality rate and should therefore be aggressively treated or prevented.

Introduction: Morbidity and mortality from opioid overdoses continue to be a significant issue worldwide. In Alberta, there was a 40% increase in accidental opioid-related deaths from 2016 to 2017. In response to this crisis, Alberta Health Services has dramatically expanded access to Naloxone with a province-wide program for the distribution of take-home naloxone (THN) kits. Edmonton Zone ED's began dispensing these kits in 2016. The objectives of this study are to assess the trends in THN kit distribution from these sites in 2016 and 2017. Methods: The Edmonton Zone is a health region that comprises eleven tertiary, urban community and rural community ED's. THN kits in Edmonton Zone ED's were distributed through Pyxis, an automated medication dispensing and tracking system. Pyxis data for THN kits in 2016 and 2017 was extracted for each Edmonton Zone ED and the raw numbers and trends were examined. The National Ambulatory Care Reporting System database was also analyzed to determine the number of opioid related visits to Edmonton Zone ED's over that same time period. Results: A total of 686 THN kits in the Edmonton Zone were distributed over 2016 and 2017. The two tertiary centers distributed 502 kits, while the urban and rural community emergency departments collectively distributed 184 kits. Comparing 2016 (n = 245) to 2017 (n = 441), there was an 80% overall increase in the number of kits distributed, with tertiary center ED's dispensing 92% more kits, urban community ED's 51% more and rural ED's 63% more. Over the same time period, the number of opioid related visits increased in tertiary center ED's by 78%, in urban community sites by 26%, and in rural ED's by 67%. Almost all ED's increased their THN kit distribution from year to year, though there was one urban community site that dispensed fewer kits in the second year of the program. Conclusion: Edmonton Zone ED's dispensed 686 THN kits over two calendar years. Almost every ED distributed more kits in 2017 than 2016, which likely reflects successful uptake of this harm reduction intervention by frontline ED staff. However, there is still evidence of some imbalance in THN kit allocation as the percent increase in kits distributed varied widely based on the type of ED. This data can be used to pinpoint areas in the Edmonton Zone where barriers to THN access may still exist and guide continued quality improvement interventions to increase distribution and education.

Introduction: The quick Sepsis-related Organ Failure Assessment (qSOFA) score was developed to provide clinicians with a quick assessment for patients with latent organ failure possibly consistent with sepsis at high-risk for mortality. With the clinical heterogeneity of patients presenting with sepsis, a Bayesian validation approach may provide a better understanding of its clinical utility. This study used a Bayesian analysis to assess the prediction of hospital mortality by the qSOFA score among patients with infection transported by paramedics. Methods: A one-year cohort of adult patients transported by paramedics in a large, provincial EMS system was linked to Emergency Department (ED) and hospital administrative databases, then restricted to those patients with an ED diagnosed infection. A Bayesian binomial regression model was constructed using Hamiltonian Markov-Chain Monte-Carlo sampling, normal priors for each parameter, the calculated score, age and sex as the predictors, and hospital mortality as the outcome. Discrimination was assessed using posterior predictions to calculate a “Bayesian” C statistic, and calibration was assessed with calibration plots of the observed and predicted probability distributions. The independent predictive ability of each measure was tested by including each component measure (respiratory rate, Glasgow Coma Scale, and systolic blood pressure) as continuous predictors in a second model. Results: A total of 9,920 patients with ED diagnosed infection were included. 264 (2.7%) patients were admitted directly to the ICU, and 955 (9.6%) patients died in-hospital. As independent predictors, the probability of mortality increased as each measure became more extreme, with the Glasgow Coma Scale predicting the greatest change in mortality risk from a high to low score; however, no dramatic change in the probability supporting a single decision threshold was seen for any measure. For the calculated score, the C statistic for predicting mortality was 0.728. The calibration curve had no overlap of predictions, with a probability of 0.5 (50% credible interval 0.47-0.53) for patients with a qSOFA score of 3. Conclusion: Although no single decision threshold was identified for each component measure, a calculated qSOFA score provides good prediction of mortality for patients with ED diagnosed infection. When validating clinical prediction scores, a Bayesian approach may be used to assess probabilities of interest for clinicians to support better clinical decision making. Character count 2494

Introduction: In-hospital cardiac arrest (IHCA) most commonly occurs in non-monitored areas, where we observed a 10min delay before defibrillation (Phase I). Nurses (RNs) and respiratory therapists (RTs) cannot legally use Automated External Defibrillators (AEDs) during IHCA without a medical directive. We sought to evaluate IHCA outcomes following usual implementation (Phase II) vs. a Theory-Based educational program (Phase III) allowing RNs and RTs to use AEDs during IHCA. Methods: We completed a pragmatic before-after study of consecutive IHCA. We used ICD-10 codes to identify potentially eligible cases and included IHCA cases for which resuscitation was attempted. We obtained consensus on all data definitions before initiation of standardized-piloted data extraction by trained investigators. Phase I (Jan.2012-Aug.2013) consisted of baseline data. We implemented the AED medical directive in Phase II (Sept.2013-Aug.2016) using usual implementation strategies. In Phase III (Sept.2016-Dec.2017) we added an educational video informed by key constructs from a Theory of Planned Behavior survey. We report univariate comparisons of Utstein IHCA outcomes using 95% confidence intervals (CI). Results: There were 753 IHCA for which resuscitation was attempted with the following similar characteristics (Phase I n = 195; II n = 372; III n = 186): median age 68, 60.0% male, 79.3% witnessed, 29.7% non-monitored medical ward, 23.9% cardiac cause, 47.9% initial rhythm of pulseless electrical activity and 27.2% ventricular fibrillation/tachycardia (VF/VT). Comparing Phases I, II and III: an AED was used 0 times (0.0%), 21 times (5.6%), 15 times (8.1%); time to 1st rhythm analysis was 6min, 3min, 1min; and time to 1st shock was 10min, 10min and 7min. Comparing Phases I and III: time to 1st shock decreased by 3min (95%CI -7; 1), sustained ROSC increased from 29.7% to 33.3% (AD3.6%; 95%CI -10.8; 17.8), and survival to discharge increased from 24.6% to 25.8% (AD1.2%; 95%CI -7.5; 9.9). In the VF/VT subgroup, time to first shock decreased from 9 to 3 min (AD-6min; 95%CI -12; 0) and survival increased from 23.1% to 38.7% (AD15.6%; 95%CI -4.3; 35.4). Conclusion: The implementation of a medical directive allowing for AED use by RNs and RRTs successfully improved key outcomes for IHCA victims, particularly following the Theory-Based education video. The expansion of this project to other hospitals and health care professionals could significantly impact survival for VF/VT patients.

Introduction: Drones are already being used in medicine. They are employed to transport blood products and laboratory samples in rural and remote areas and they are increasingly being tested to deliver external defibrillators outside the hospital to patients with cardiac arrest. As this technology rapidly develops and attracts the attention of the scientific community, we present a rapid systematic review protocol that aims to synthesize the scientific evidence that has tested the use of drones to provide emergency medical care. Methods: A search strategy incorporating the concepts of ‘drone’ and ‘emergency medicine’ was launched in 52 bibliographic databases, including CINAHL and PubMed. Using the artificial intelligence module included in DistillerSR, a reviewer completed the first screening phase by reading the title and abstract of the retrieved articles. To be included, articles had to report empirical research projects that tested the potential uses of drones to improve the quality and accessibility of emergency medical care. These selection criteria were applied to the full text of the included articles during the second screening phase by a single reviewer. The results of these two screening phases will be validated by a second independent reviewer. The bibliography of included studies, relevant scientific journals and literature reviews will be manually searched for relevant articles. Results: The search strategy retrieved 1809 articles, of which 22 met our inclusion criteria in the first and second screening phases. Of these, one study used an empirical research design (qualitative interviews) to evaluate the usefulness of drones in emergency medicine, 17 used simulations or scenarios, and four were comprehensive literature reviews on the use of drones to provide healthcare. The final review will synthesize evidence related to the use of drones in emergency medicine and its impact on emergency medical services: nature of the emergency situation (cardiac arrest, blood transfusion), type of drone (fixed wing, quadcopter), tasks performed by drones (transport, surveillance), improvement in access or quality of care (patient's health, time saved in providing services). Conclusion: Drone technology is evolving rapidly and the indications for its use in providing emergency care is increasing. This rapid systematic review will focus on scientific studies aimed at testing the effectiveness of drones to improve the quality and access to emergency medical care.

Introduction: Patient assessment is a fundamental feature of non-emergency community paramedicine (CP) home visit programs. In the absence of a recognized standard for CP assessment, current assessment practices in CP programs are unknown. Without knowing what community paramedics are assessing, it is difficult to ascertain what should be included in patient care plans, whether interventions are beneficial, or whether paramedics are meeting program objectives. Our objective was to summarize the content of assessment instruments used in CP programs in order to describe the state of current practice. Methods: We performed an environmental scan of all CP programs in Ontario, Canada, and employed content analysis to describe current assessment practices in CP home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. Findings were compared at the domain and sub-domain of the ICF. Results: Of 54 paramedic services in Ontario, 43 responded to our request for information. Of 24 services with CP home visit programs, 18 provided their intake assessment forms for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Overall, most assessments included some content from each of the domains outlined in the ICF, including: Impairments of Body Functions, Impairments of Body Structures, Activity Limitation and Participation, and Environmental Factors. At the sub-domain level, only assessment of Impairments of the Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems appeared in all assessments. Few CP home visit program assessments covered most ICF sub-domain categories and many items classified to specific categories were included in only a few assessments. Conclusion: CP home visit programs complete multi-domain assessments as part of patient intake. The content of CP assessments varied across Ontario, which suggests that care planning and resources may not be consistent. Current work on practice guidelines and paramedic training can build from descriptions of assessment practices to improve quality of care and patient safety. By identifying what community paramedics assess, evaluation of the quality of CP home visit programs and their ability to meet program objectives can be improved and benchmarks in patient care can be established.

Introduction: Elderly patients with comorbid illness have poor meaningful recovery after out of hospital cardiac arrest. Many elderly patients decide that if they have a cardiac arrest, they would want not want resuscitation. In Ontario, prehospital personnel must provide resuscitation to all patients regardless of previously stated wishes or legal documentation unless they are presented a Ministry of Health mandated ‘Do Not Resuscitate’ Confirmation Form (MOH-DNRCF). This study aimed to evaluate the awareness of this form as well as any barriers to its completion. Methods: Patients over 70 years of age presenting to the Emergency Department were approached to complete a short survey about their wishes regarding resuscitation, awareness of the MOH-DNRCF, as well as any barriers to completion. Standard demographic variables were also collected. Patients, with critical illness, with severe dementia, a language barrier or from a nursing home were excluded. The primary outcome was awareness of the MOH-DNRCF. Standard descriptive statistics were summarized using median [IQR] and simple proportions. Results: Preliminary data of 96 patients has been collected. The median [IQR] age of patients recruited was 81 [75-88] years and 54% were female. 49/96 (51%) have wishes to not be resuscitated in the event of cardiac arrest and of those 42 (86%) are not aware of the existence of the MOH-DNRCF. Of the 7 patients who were aware of the form only 1 had completed one. Barriers to completion included the patient being unsure where to access the form and difficulty in discussing the topic. Conclusion: The majority of patients with wishes to be DNR are unaware of the MOH-DNRCF. This has severe repercussions as, in the event of an out of hospital cardiac arrest, these patients would be resuscitated by prehospital care providers. Strategies to increase awareness of the form as well as strategies to increase ease of access should be considered to avoid resuscitation that is against patient wishes.