Introduction: Competence committees (CCs) struggle with incorporating professionalism issues into resident progression decisions. This study examined how professionalism concerns influence individual faculty decisions about resident progression using simulated CC reviews. Methods: In 2017, the investigators conducted a survey of 25 program directors of Royal College emergency medicine residency training programs in Canada and those faculty members who are members of the CCs (or equivalent) at their home institution. The survey contained twelve resident portfolios, each containing formative and summative information available to a CC for making progression decisions. Six portfolios outlined residents progressing as expected and six were not progressing as expected. Further, a professionalism variable (PV) was added to six portfolios, evenly split between those residents progressing as expected and not. Participants were asked to make progression decisions based on each portfolio. Results: Raters were able to consistently identify a resident needing an educational intervention versus those who did not. When a PV was added, the consistency among raters decreased by 34.2% in those residents progressing as expected, versus increasing by 3.8% in those not progressing as expected (p = 0.01). Conclusion: When using an unstructured review of a simulated resident portfolio, individual reviewers can better discriminate between trainees progressing as expected when professionalism concerns are added. Considering this, educators using a competence committee in a CBME program must have a system to acquire and document professionalism issues to make appropriate progress decisions.

Introduction: By virtue of the nature of their work, emergency medicine physicians and residents experience high cognitive load and stress, which are known to affect physician performance and patient outcomes. However, the contribution of cognitive load has not previously been measured during the clinical work of emergency physicians. The objectives of this study were to measure cognitive load and stress in emergency physicians and residents during clinical work, evaluate the relative contribution of multiple factors on cognitive load, and to determine the effect of experience on these results. Methods: This observational study was conducted at an academic Canadian Urgent Care Centre from July to August 2018. Emergency medicine residents and staff physicians completed a survey while on shift to evaluate measures of cognitive load and acute stress. Patient acuity and the number of active patients for each physician, hours worked and patients in the waiting room were recorded. Correlational analyses and multivariable linear regression were performed to evaluate the effect of each predictor on measures of overall cognitive load. Results: A total of 131 questionnaires were completed by 42 physicians (87 questionnaires from 26 staff physicians and 44 questionnaires from 16 residents). Results showed that staff physicians carried a significantly higher patient load compared to residents (p < 0.001). There were no differences in mean overall cognitive load (p = 0.25), acute stress (p = 0.17) or measured subcomponents of cognitive load between the two groups. Perceived case difficulty and acute stress were strong predictors of overall cognitive load, while level of distraction did not correlate with the other outcomes. The number of patients in the waiting room predicted acute stress in staff physicians, while the number of higher acuity patients was a significant predictor in residents. Conclusion: Measures of overall cognitive load and acute stress were strongly correlated in the clinical setting. Different factors affect cognitive load and acute stress in staff physicians compared to residents. Appreciating these differences may help medical educators understand the cognitive challenges faced by learners in a clinical context, and aid in the design of cognitive and educational strategies to help mitigate these challenges and reduce stress.

Introduction: Different tools have been developed to complement medical training, and improve student learning. Although social media has been described as an innovative educational strategy, evidence for its use is scarce in emergency medicine (EM). The primary outcome of this study was to evaluate whether brief teaching points (tweets) sent to medical students (MS) via a Twitter feed, would yield better exam score at the end of an emergency medicine (EM) rotation. Methods: Participants included in this prospective cohort study were MS completing an EM rotation at our tertiary care academic center. The control group was recruited from December 2016 to November 2017 and the experimental group from November 2017 to November 2018. The MS in the experimental group were invited to follow a Twitter feed. A total of 32 EM-related tweets based on learning objectives were sent out throughout the 4 week rotation. At the end of the rotation, MS of both cohorts took an exam and completed a survey of assiduity and appreciation. Exam scores were compared using t-tests. Results: A total of 80 MS were recruited for the study, 38 in the experimental cohort. Average exam scores were similar in both cohorts (control = 63 ± 9% vs experimental = 64 ± 8% for a mean difference of -2% [95%CI -6 to 2], p = 0.37). Of the experimental group, only 7 (18%) of the participants reported viewing more than 50% of the tweets. There was no difference between mean exam scores of this sub-group and that of the control cohort (66 ± 10% for a mean difference of 4% [95%CI -4 to 11], p = 0.33). The majority (n = 20, 53%) of the MS in the experimental cohort did not read any tweets. When compared to the rest of the experimental cohort MS who reported viewing ≥50% of the tweets found the Twitter feed to be a useful educational tool. Indeed, on a 3 item Likert scale used to evaluate different aspects of appreciation, they found the Twitter feed to be beneficial to their rotation (86% vs 13%, p < 0.001) as well as helpful in patient management (71% vs 16%, p = 0.001). These same MS would have liked more tweets (100% vs 19%, p < 0.001) and would like to use Twitter in other rotations (100% vs 32%, p = 0.005). Conclusion: In this study, there was no difference in the exam scores between MS having access to regular EM-focused educational tweets in comparison to those who did not. Results also found a lower than expected assiduity of MS to the educational Twitter feed, although those who used it significantly found it useful.

Introduction: Over 150 Off Service Residents from 18 different programs rotate through our ED every academic year. We aim to determine the educational needs of these residents to we better design a curriculum for their ED rotation. Methods: We conducted a cross-sectional convenience sample survey of 133 Off-Service PGY-2 residents who had rotated through the ED of The Ottawa Hospital in their PGY-1 year. (from July 2016 to June 2017). The survey was emailed to residents from March to May 2018 and consisted of 19 questions. Questions were qualitative, selection from list and rank order. They focused on 3 main areas: EM rotation impact and areas for improvement, desired content, desired method of learning. Data was collected using Survey Monkey. Results: We received 70 responses (53%) from 13 different residency programs. 36 (51.4%) of respondents were from the Family Medicine program. Qualitative themes included that the ED provides great opportunity to develop the ability to workup undifferentiated patients and allows for teaching around cases. Allowing more involvement in acute care cases and having more SIM sessions could improve the rotation. The most useful topic was chest pain/cardiovascular conditions (73.3% of residents) with 16 additional ED topics listed as important for their practice. The most useful skill was suturing (51.6% of residents) with 16 other ED procedures listed as important for their practice. The preferred teaching method was SIM (48.3%) followed by small group teaching (33.3%). Conclusion: The emergency department provides an excellent learning environment for a large range of Off-Service residents early in their training. In addition to clinical shifts, a curriculum incorporating simulation and small group teaching and that covers a large scope of topics is necessary to meet the needs of these residents.

Introduction: Short-term gains in knowledge and skills of critical emergency procedures are demonstrated after simulation, but there is uncertainty regarding long term retention. Our objective was to determine whether simulation of critical emergency procedures promotes long term retention of procedural skills in non-surgical physicians likely to perform them. Methods: MEDLINE and Embase (from start of database to June 2018) and the CENTRAL Trials Registry of the Cochrane Collaboration (May 2018 Issue) were searched using a peer-reviewed strategy. Studies were eligible if they (1) were observational cohorts, quasi-experimental or randomized controlled trials, (2) assessed intubation, cricothyrotomy, periocardiocentesis, tube thoracostomy or central line placement performance by non-surgical physicians, (4) utilized any form of simulation (all levels of realism and technology), and (4) assessed skill performance immediately after and at ≥3 months post-simulation. There was no language restriction. Two reviewers independently assessed article eligibility. One reviewer extracted data and assessed study quality. Primary outcome was skill performance 3 months post-simulation. Secondary outcomes included skill performance at 6 and ≥12 months post-simulation, and skill competency at 3 months post-simulation. Results: 1370 citations were identified. 12 studies were eligible. Methodological quality was uniformly poor with high risk of bias, lack of defined primary outcomes, inadequate sample sizes, and non-standardized, unvalidated tools of unclear clinical significance. Given significant heterogeneity in design, populations, procedures, and outcome timing, a narrative synthesis of results was undertaken. In 10 studies participants’ performance at 3, 6 and 12 months retention testing remained above baseline assessment. However, 3 studies showed a significant decrease in performance at 3 months post-simulation compared to immediately post-simulation. Performance was also lower in 2 studies at 6 months post-simulation, and 2 studies at ≥12 months post-simulation. Four studies assessed competency and 3 demonstrated maintenance of competency. Conclusion: There was significant heterogeneity and poor methodological quality among the eligible studies. Results were conflicting for retention of procedural skills and competency. Future directions should include development of robust assessment tools, and improved research methodology of simulation education targeted at critical procedural skills.

Introduction: With a shift towards competency-based medical education, it is crucial to not only emphasize learner abilities such as clinical skills but also leadership in the conduct of research. Though the Royal College of Physicians and Surgeons of Canada's (RCPSC) training objectives for Emergency Medicine (EM) residents state that the specialist physician be able to describe the principles of research, the research methodology curriculum across EM training programs in Canada is likely variable. The primary goal of this study was to describe the variability of research methodology teaching among RCPSC-EM residency programs. Methods: An electronic survey was distributed to English-speaking RCPSC-EM program directors (PDs) and EM residents. The survey investigated residents' and PDs’ thoughts on the adequacy of their local curriculum and asked them to quantify their research methodology teaching. The primary outcome was the frequency and content of current research methodology and research ethics teaching as well as a description of scholarly project requirements of EM residency programs across Canada. The data was presented with simple descriptive statistics. Results: 79 EM residents and 7 PDs responded (response rate 22.3% and 58.3%, respectively). All 7 PDs indicate having a research methodology curriculum while 71.6% of residents are aware of this curriculum. Only 57.1% of PDs report having formal assessments. Most programs (71.4%) teach via small groups while 28.6% of programs use large group sessions. Residents identify teaching as led by research staff (68.9%), staff physicians (60%), and EM researchers (57.8%), while only 17.8% use outside educators. Students noted various modalities of curriculum feedback such as online surveys, weekly forms, and verbal feedback. Regarding the strength of the curricula, 85.7% of PDs believed their curriculum prepares residents for board exams, while only 62.2% of residents felt similarly. When asked about using a standard web-based curriculum module if available, 60.5% of residents responded in favour. Conclusion: This study demonstrates that EM residency programs across Canada vary with respect to research methodology curriculum and discrepancies exist between residents’ and program directors’ perceptions of the curriculum. Given the lack of a standardized research methodology curriculum for these residency programs, there is an opportunity for curriculum development to improve training in research methodology.

Introduction: Quality improvement and patient safety (QIPS) are increasingly recognized as integral to the provision and advancement of emergency medicine (EM) care. In 2015, QIPS were added to the Canadian Medical Education Directives for Specialists (CanMEDS) framework. However, the level of QIPS education and support that Canadian EM residents receive is unknown. In order to better plan national QIPS efforts aimed at enabling EM residents to improve their local care settings, we sought to assess the current state of QIPS education and support in Canadian EM residency programs. Methods: This was a descriptive, cross-sectional electronic survey that was disseminated to all current Canadian EM residents from both Royal College (RC) and Family Medicine - EM training streams. Residents were recruited either directly or through their program's administrative assistant. The survey consisted of multiple-choice, Likert and free-text entry questions. Themes included a) familiarity with QIPS; b) local opportunities for QIPS projects and mentorship; and c) desire for further QIPS education and involvement. The survey was open for a five-week period, with formal reminders after the first and third weeks. Descriptive statistics are reported. Results: 189 (35%) of 535 current EM residents completed the survey, representing all 17 medical schools. 77% of respondents were from the RC stream. 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS. 47.2% of respondents reported “not knowing” or “not having readily available” QIPS projects to participate in their local environment, and 51.5% had equivalent responses with respect to QIPS mentorship opportunities. Only 17.5% of respondents reported that QIPS methodologies were already formally taught in their residency program, and 66.9% indicated a desire for increased QIPS teaching. The majority of respondents were “slightly” (35.9%), “moderately” (23.2%) or “very” (11.3%) interested in becoming involved with QIPS training and initiatives. Conclusion: Responding Canadian EM residents are interested in obtaining greater QIPS education as well as project and mentorship opportunities, but many perceive that they do not have adequate access to these at the current time. As the importance of QIPS increases in the EM community, supporting residents with more robust educational infrastructures may be necessary. Future efforts may include the standardizing of QIPS postgraduate curricula and improving access to QIPS opportunities across the country.

Introduction: Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children. However, studies to date have been limited by small samples and imprecise estimates of effect size. We sought to summarize the evidence on the effectiveness of IND for procedures associated with distress in children. Methods: We performed electronic searches of MEDLINE (1946-2018), EMBASE (1980-2018), Google Scholar (2018), CINAHL (1981-2018), Cochrane Central Register of Controlled Trials (2018), 6 clinical trials registries and conference proceedings (2010-2018). Title searches, data abstraction, and risk of bias assessments were performed in duplicate. We included all published and unpublished, randomized and quasi-randomized trials of IND for procedures in children younger than 19 years of age without language restriction. The methodological quality of studies was evaluated using the Cochrane Collaboration's Risk of Bias tool. The primary outcome was the proportion of participants that were deemed to be adequately sedated for the procedure. Results: Of 661 studies, 18 met inclusion criteria. Trials involved 2128 participants, age 1 month - 14 years (836, 39.3% females), who received IND 1 - 4 mcg/kg either by drops (n = 12), atomizer (n = 4), or both (n = 2). 12 trials were eligible for meta-analysis. 13 trials used validated instruments to assess sedation. All studies except one were associated with low or moderate risk of bias. For painful procedures (IV insertion; laceration repair; dental extraction), the pooled OR (95% CI) for adequate sedation and need for additional analgesia was non-significant [1.19 (0.53, 2.65)] and [2.16 (0.62, 7.49)], respectively (n = 5). For non-painful procedures (diagnostic imaging), the corresponding pooled OR (95% CI) favored IND [3.04 (1.58, 5.82)] and [4.44 (2.11, 9.35)], respectively (n = 7). Time to onset and duration of sedation ranged from 13-31 minutes and 41-91.5 minutes, respectively. For adverse effects, the pooled OR (95% CI) was not significantly different between IND and comparators [0.58 (0.22, 1.55] and there were no serious adverse events. Conclusion: IND at doses 1 to 4 mcg/kg are safe and adequately sedate children undergoing non-painful procedures, although the ease of administration must be weighed against the risk of prolonged sedation. Additional trials with larger sample sizes and greater methodologic rigor are needed for painful emergency department procedures such as laceration repair and IV insertion.

Introduction: Intravenous insertion (IVI) is identified by children as extremely painful and the resultant distress can have lasting negative consequences. There is an urgent need to effectively manage such procedures. Our primary objective was to compare the pain and distress of IVI with the addition of humanoid robot-based distraction to standard care, versus standard care alone. Methods: This two-armed randomized controlled trial (RCT) was conducted from April 2017 to May 2018 at the Stollery Children's Hospital emergency department (ED). Children aged 6 to 11 years who required IVI were included. Exclusion criteria included hearing or visual impairments, neurocognitive delays, sensory impairment to pain, previous enrolment, and discretion of the ED clinical staff. Primary outcomes were measured using the Observational Scale of Behavioural Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). A total of 426 pediatric patients were screened and 340 were excluded. Results: We recruited 86 children, of which 55% (47/86) were male; 9% (7/82) were premature at birth; 82% (67/82) had a previous ED visit; 30% (25/82) required previous hospitalization; 78% (64/82) had previous IV placement and 96% (78/81) received topical anesthesia. The mean total OSBD-R score was 1.49 ± 2.36 (standard care) compared to 0.78 ± 1.32 (robot group) (p = 0.047). The median FPS-R during the IV procedure was 4 (IQR 2,6) in the standard care group alone, compared to 2 (IQR 0,4) with the addition of humanoid robot-based distraction (p = 0.10). Change in parental state anxiety pre-procedure versus post-procedure was not significantly different between groups (p = 0.49). Parental satisfaction with the IV start was 93% (39/42) in the robot arm compared to 74% (29/39) in the standard care arm (p = 0.03). Parents were also more satisfied with management of their child's pain in the robot group (95% very satisfied) compared with standard care (72% very satisfied) (p = 0.002). Conclusion: A statistically significant reduction in distress was observed with the addition of robot-based distraction to standard care. Humanoid robot-based distraction therapy reduces distress and to a lesser extent, pain, in children undergoing IVI in the ED. Further trials are required to confirm utility in other age groups and settings.

Introduction: Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. The objective of this review was to investigate the ability of the HEART score to predict major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS. Methods: Eleven databases and other sources identified 468 potentially relevant studies. Sixty-seven studies underwent full text review with 25 studies meeting eligibility criteria. Main outcome measures were pooled prevalence, risk ratio (RR), and absolute risk reduction (ARR) for MACE within six weeks of ED evaluation, comparing HEART score 0–3 versus 4–10. Model discrimination (sensitivity, specificity, concordance statistic) and calibration (observed to expected events ratio) were also evaluated. Results: Data from 25 studies including 41,397 patients were combined in the meta-analysis. In total, 4815 patients (11.6%) developed MACE. Among 18,866 patients with HEART score 0–3, 396 (2.1%) developed MACE (RR 0.08; ARR 0.20). Outcome measures were consistent across planned subgroup and sensitivity analyses. Among studies with secondary outcome data for patients with HEART score 0–3, 5 of 6461 (0.1%) died and 75 of 7556 (1.0%) had a myocardial infarction. Conclusion: The HEART score provides a reliable quantitative risk assessment of MACE in ED patients with possible ACS. Emergency clinicians should consider using the HEART score to facilitate risk communication and shared decision making with patients and other care providers.

Introduction: Risk-stratification of patients requiring endotracheal intubation and mechanical ventilation in the Emergency Department (ED) is necessary for informed discussions with patients regarding goals-of-care. Frailty is a clinical state characterized by reduced physiologic reserve, and resulting from accumulation of physiological stresses and comorbid disease. Frailty is increasingly being identified as an important independent predictor of outcome among critically ill patients. Our objective was to identify the impact of clinical frailty (defined by the Clinical Frailty Scale [CFS]) on in-hospital mortality and resource utilization of ED patients requiring endotracheal intubation and mechanical ventilation. Methods: We analyzed a prospectively collected registry (2011-2016) of patients requiring endotracheal intubation in the ED at two academic hospitals and six community hospitals. We included all patients ≥18 years of age, who survived to the point of ICU admission. All patient information, outcomes, and resource utilization were stored in the registry. CFS scores were obtained through chart abstraction by two blinded reviewers. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model, controlling for confounding variables (including patient sex, comorbidities, and illness severity). We defined “frailty” as a CFS ≥ 5. Results: 4,622 patients were included. Mean age was 61.2 years (SD: 17.5), and 2,614 (56.6%) were male. Frailty was associated with increased risk of in-hospital mortality, as compared to those who were not frail (adjusted odds ratio [OR] 2.21 [1.98-2.51]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted OR 1.78 [1.56-2.01]) among patients initially from a home setting. Frail patients were more likely to fail extubation during their hospitalization (adjusted OR 1.81 [1.67-1.95]) and were more likely to require tracheostomy (adjusted OR 1.41 [1.34-1.49]). Conclusion: Presence of frailty among ED patients requiring endotracheal intubation and mechanical ventilation was associated with increased in-hospital mortality, discharge to long-term care, extubation failure, and tracheostomy. ED physicians should consider the impact of frailty on patient outcomes, and discuss associated prognosis with patients prior to intubation.

Introduction: A significant gap exists between the number of people waiting for an organ and donors. There are currently 1,628 people awaiting organ donation in Ontario alone. In 2018 to date, 310 donors have donated 858 organs. The purpose of this study was to determine whether there were missed donors in the Emergency Department (ED) and by what percent those missed donors would increase organ donation overall. Methods: This was a health records and organ donation database review of all patients who died in the ED at a large academic tertiary care center with 2 campuses and 160,000 visits per year. Patients were included from November 1, 2014 – October 31, 2017. We collected data on demographics, cause of death, and suitability for organ donation. Data was cross-referenced between hospital records and the provincial organ procurement organization called Trillium Gift of Life Network (TGLN) to determine whether patients were appropriately referred for consideration of donation in a timely manner. Potential missed donors were manually screened for suitability according to TGLN criteria. We calculated simple descriptive statistics for demographic data and the primary outcome. The primary outcome was percentage of potential organ donors missed in the Emergency Department (ED). Results: There were 606 deaths in the ED from November 1, 2014 – October 31, 2017. Patients were an average of 71 years old, 353 (58%) were male, and 75 (12%) died of a traumatic cause. TGLN was not contacted in 12 (2%) of cases. During this period there were two donors from the ED and 92 from the ICU. There were ten missed potential donors. They were an average of 67 years, 7 (70%) were male, and 2 (20%) died of a traumatic cause. In all ten cases, patients had withdrawal of life sustaining measures for medical futility prior to TGLN being contacted for consideration of donation. There could have been an addition seven liver, six pancreatic islet, four small bowel, and seven kidney donors. The ten missed ED donors could have increased total donors by 11%. Conclusion: The ED is a significant source of missed organ donors. In all cases of missed organ donation, patients had withdrawal of life sustaining measures prior to TGLN being called. In the future, it is essential that all patients have an organ procurement organization such as TGLN called prior to withdrawal of life sustaining measures to ensure that no opportunity for consideration of organ donation is missed.

Introduction: Hypotension is known to be associated with increased mortality in severe traumatic brain injury (TBI) patients. Systolic blood pressure (SBP) of <90 mmHg is the threshold for hypotension in consensus TBI treatment guidelines; however, evidence suggests hypotension should be defined at higher levels for these patients. Our objective was to determine the influence of hypotension on mortality in TBI patients requiring ICU admission using different thresholds of SBP on arrival at the emergency department (ED). Methods: Retrospective cohort study of patients with severe TBI (Abbreviated Injury Scale Head score ≥3) admitted to ICU at the QEII Health Sciences Centre (Halifax, Canada) between 2002 and 2013. Patients were grouped by SBP on ED arrival ( <90 mmHg, <100 mmHg, <110 mmHg). We performed multiple logistic regression analysis with mortality as the dependent variable. Models were adjusted for confounders including age, gender, Injury Severity Score (ISS), injury mechanism, and trauma team activation (TTA). Results: A total of 1233 patients sustained a severe TBI and were admitted to the ICU during the study period. The mean age was 43.4 ± 23.9 years and most patients were male (919/1233; 74.5%). The most common mechanism of injury was motor vehicle collision (491/1233; 41.2%) followed by falls (427/1233; 35.8%). Mean length of stay in the ICU was 6.1 ± 6.4 days, and the overall mortality rate was 22.7%. SBP on arrival was available for 1182 patients. The <90 mmHg group had 4.6% (54/1182) of these patients; mean ISS was 20.6 ± 7.8 and mortality was 40.7% (22/54). The <100 mmHg had 9.3% (110/1182) of patients; mean ISS was 19.3 ± 7.9 and mortality was 34.5% (38/110). The <110 mmHg group had 16.8% (198/1182) of patients; mean ISS was 17.9 ± 8.0 and mortality was 28.8% (57/198). After adjusting for confounders, the association between hypotension and mortality was 2.22 (95% CI 1.19-4.16) using a <90 mmHg cutoff, 1.79 (95% CI 1.12-2.86) using a <100 mmHg cutoff, and 1.50 (95% CI 1.02-2.21) using a <110 mmHg cutoff. Conclusion: While we found that TBI patients with a SBP <90 mmHg were over 2 times more likely to die, patients with an SBP <110 mmHg on ED arrival were still 1.5 times more likely to die from their injuries compared to patients without hypotension. These results suggest that establishing a higher threshold for clinically meaningful hypotension in TBI patients is warranted.

Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.

Introduction: The number of CT scans prescribed in the Emergency department (ED) for suspected renal colic has increased over recent years without an associated improvement in patient-centred outcomes. We assessed whether Point-of-Care Ultrasound (PoCUS) decreases the use of formal radiologic imaging. Methods: We completed a retrospective cohort study on consecutive patients 18 years of age and older presenting to the ED with suspected uncomplicated renal colic in a tertiary care centre in Québec in 2016. Exclusion criteria included: previous urologic intervention, solitary kidney, dialysis, fever, pyuria, acute kidney injury, pregnancy, suspicion of a serious alternative diagnosis or persistent symptoms despite analgesia. We compared the proportion (95%CI) of formal radiologic imaging performed (Ultrasound or CT) in patients who had PoCUS in the ED vs. those who did not. Two-tailed Fisher exact test (α = 0.05) and odds ratios (95%CI) calculated from multivariate logistic regression models adjusted for age, gender, Charlson Index and previous renal colic were used to compare the two groups. The reliability of data collection was evaluated with a kappa score (95%CI). Results: 169 patients with uncomplicated renal colic were included. There was no difference between the groups in terms of age, gender, Charlson Index, or previous renal colic. The PoCUS level of training and the doctor's education level was significantly higher in the PoCUS group. There was a non-significant trend towards less formal imaging in patients of the PoCUS group 65/88 (73.9% [63.4-82.7%]) vs. the non-PoCUS group 69/81 (85.2% [75.6-92.1%]), p = 0.087. After adjustment for confounders, the patients not evaluated with PoCUS were more likely to have formal imaging with a significant odds ratio of 2.41 [1.05-5.56]). Among patients who underwent a CT, incidentalomas were found in 16.5% and only 2.0% demonstrated significant findings leading to changes in ED management, such as an alternative diagnosis, need for admission, or an urgent urological intervention. Inter-observer agreement was excellent between assessers with a kappa score of 0.88 [0.66-1.00]. Conclusion: ED patients with uncomplicated renal colic who are investigated with PoCUS tend to have fewer formal imaging test. When CT scans were performed, incidentalomas were found in 16.5% and ED management changed only 2.0% of the time. PoCUS appears to be a useful tool for decreasing CT utilisation in this low-risk ED population.

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Introduction: The Canadian C-Spine rule (CCR) was validated for use by paramedics to selectively immobilize stable trauma patients. However, the CCR “Dangerous Mechanism” is highly prevalent in sports. Our objective was to compare the CCR performance in sport-related vs. non-sport-related injuries and describe sport-related mechanisms of injury. Methods: We reviewed data from the prospective paramedic CCR validation and implementation studies in 7 Canadian cities, which already included identification of sport-related injuries. A single trained reviewer further categorized mechanisms of injury using a pilot-tested standardized form, with the aid of a sport medicine physician in 15 ambiguous cases. We compared the CCR's recommendation to immobilize sport-injured versus non-sport-injured patients using chi-square and relative risk statistics with 95% confidence intervals. Results: There were 201 amateur sport-injuries among the 5,978 patients. Sport-injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs 46.8%) than non-sport-injured patients. Paramedics did not miss any c-spine injuries when using the CCR. Although cervical spine injury rates were similar between sport (2/201; 1.0%) and non-sport injured patients (47/5,777; 0.8%), the absolute number of sport-related injuries was very small. Although CCR recommended immobilization equally between the two groups (46.4% vs 42.5% p = 0.29; RR 1.17 95%CI 0.87-1.57), the reason for immobilization was more likely to be a dangerous mechanism in sport injuries (68.6% vs 54.5%, p = 0.012). Although we observed a wide range of mechanisms, the most common dangerous mechanism responsible for immobilization in sport was axial load. Conclusion: The CCR identified all significant c-spine injuries in a cohort of patients assessed and transported by paramedics. Although an equal proportion of sport and non-sports related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the CCR to evaluate all sport-related injuries in collegiate or pro athletes evaluated by sport medicine therapists and physicians, as these patients are rarely assessed by paramedics or transported to a hospital. It does support the safety and benefit of using the CCR in sport-injured patients for which paramedics are called.

Introduction: Successful resuscitation in the ED cannot occur without a viable patient, and in many cases patient viability is dependent upon optimal prehospital resuscitation performed by ad hoc teams formed in real time. Currently, little is known about the cognitive and interpersonal skills, or non-technical skills, that are essential for effective team collaboration under these conditions. We have completed a scoping review to provide a state of the literature and develop a taxonomy of the non-technical skills pertinent to ad hoc teams in prehospital settings. Methods: Our scoping review searched four databases (EMBASE, Medline, Cinahl, and Psychinfo) for articles related to resuscitation in acute care settings. No date criteria were applied, but only full text articles written in English were included. Articles underwent two-reviewer title & abstract screening, full text screening, and analysis. A quality review asked three questions: Are keywords defined? Is the article well-situated within the existing literature? Does the article contribute back to the existing body of knowledge? Although statistical analyses are not appropriate for this scoping review, analysis included a descriptive-analytical framework for organizing data. Results: Of 6932 screened articles, 38 were included in analysis, five articles examined prehospital teams, and one addressed the ad hoc nature of these teams. Only one of these articles met our three quality criteria. Nevertheless, our analysis suggests a rudimentary taxonomy whereby the primary objective of a team leader is to overcome this barrier by facilitating the development of optimal team situational awareness, fostered through timely and accurate briefings with closed-loop communication. Conclusion: This scoping review has identified that non-technical skills pertaining to resuscitation in acute care settings are becoming a widely examined phenomenon; however, few studies contribute in any meaningful way to our understanding of how non-technical skills training can be tailored to those performing as members of ad hoc prehospital resuscitation teams. As the need for interprofessional training is becoming more pressing, we anticipate this review will provide essential guidance for future inquiry as well as design for both educational models and organizational systems-based interventions.

Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.

Introduction: Delay of hospital admission until completion of assessment by consultants is a major contributor to emergency department (ED) crowding. We measured emergency physicians’ (EP) ability to predict patient admission, and estimated potential time saved if EPs could request a bed at the time of consultation. Methods: This is a prospective cohort study in a tertiary care center over 4 months using a convenience sample of ED patients requiring consultation. We consecutively recruited patients from purposefully selected shifts to balance day of the week and time of day. We excluded patients younger than 18 years or those likely to be admitted (traumas, strokes, STEMI codes, and CTAS1). We asked EPs to predict patient disposition (admission or alternate disposition) just before consultation. We defined admission as: admission to any service, admission within 48 hours of ED discharge, patients held overnight without bed request, or if bed request was delayed by 12 or more hours, and alternate disposition as any other disposition. We present EP prediction test characteristics using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI). The potential time saved was calculated from consultation to bed request for admitted patients. Results: Characteristics for the 454 included patients were: mean age 60.1 years, 48.4% male, 46.9% evening presentation, 69.4% were admitted (most commonly by Internal Medicine 26.9%), and median consult to bed request time was 3.5 hours (interquartile range 2.0 – 5.3 hours). Overall EP prediction sensitivity, specificity, PPV and NPV were 90.5% (95%CI 86.7-93.5), 84.2% (95%CI 77.0-89.8), 92.8% (95%CI 89.8-95.0) and 79.6% (95%CI 73.4-84.7) respectively. In other words, EPs correctly predicted 92.8% of patient admissions. The PPV for Internal Medicine was 95.7% (95%CI 89.7-98.4) and ranged from 78.9% (95%CI 53.9-93.0) for Psychiatry to 100% (95%CI 78.1-100) for Family Medicine. A total of 1113.5 hours of ED stretcher time (37.1 hours per shift) could have been saved if EPs initiated a concurrent bed request at time of consultation. Conclusion: EPs correctly predicted 92.8% of patient admissions across a broad field of disciplines. We estimate 1113.5 hours of ED stretcher time could have been saved over the study period if EPs triggered an inpatient bed request at the time of consultation, rather than waiting for the consultants’ disposition decision.