Innovation Concept: The fairness of the Canadian Residency Matching Service (CaRMS) selection process has been called into question by rising rates of unmatched medical students and reports of bias and subjectivity. We outline how the University of Saskatchewan Royal College emergency medicine program evaluates CaRMS applications in a standardized, rigorous, equitable and defensible manner. Methods: Our CaRMS applicant evaluation methods were first utilized in the 2017 CaRMS cycle, based on published Best Practices, and have been refined yearly to ensure validity, standardization, defensibility, rigour, and to improve the speed and flow of data processing. To determine the reliability of the total application scores for each rater, single measures intraclass correlation coefficients (ICCs) were calculated using a random effects model in 2017 and 2018. Curriculum, Tool or Material: A secure, online spreadsheet was created that includes applicant names, reviewer assignments, data entry boxes, and formulas. Each file reviewer entered data in a dedicated sheet within the document. Each application was reviewed by two staff physicians and two to four residents. File reviewers used a standardized, criterion-based scoring rubric for each application component. The file score for each reviewer-applicant pair was converted into a z-score based on each reviewer's distribution of scores. Z-scores of all reviewers for a single applicant were then combined by weighted average, with the group of staff and group of residents each being weighted to represent half of the final file score. The ICC for the total raw scores improved from 0.38 (poor) in 2017 to 0.52 (moderate) in 2018. The data from each reviewer was amalgamated into a master sheet where applicants were sorted by final file score and heat-mapped to offer a visual aid regarding differences in ratings. Conclusion: Our innovation uses heat-mapped and formula-populated spreadsheets, scoring rubrics, and z-scores to normalize variation in scoring trends between reviewers. We believe this approach provides a rigorous, defensible, and reproducible process by which Canadian residency programs can appraise applicants and create a rank order list.

Innovation Concept: Emergency Medicine (EM) residency programs in Canada have transitioned to competency based medical education and the first stage of the curriculum focuses on standardizing learner competency. Pre-internship boot camps provide a focused opportunity to assist with this standardization prior to residency training. The objective of this descriptive review was to describe our institution's EM pre-internship boot camp in the context of current literature and to summarize the state of EM boot camp curricula across all reported EM residency programs. Methods: The description of our two-day boot camp included its curriculum design, required preparation and resources, and a detailed timeline of each day's events. To compare our boot camp to current literature, a comprehensive search of both primary and gray literature was performed. Curriculum, Tool or Material: Our institution's boot camp is two days of teaching focused on clinical knowledge and procedural competency, with a large component centered on simulation. Day one consisted of an introduction to the boot camp, a review of crisis resource management principles and advanced cardiac life support (ACLS) algorithms, ACLS simulation sessions, and small group skill sessions on common emergency department procedures. Day two contained a point of care ultra sound lecture, an ultrasound guided central venous catheterization session, pigtail and chest tube insertion sessions, and high-fidelity simulation cases. In comparison to the other pre-internship boot camps that were identified in the literature, our boot camp offers a unique focus and format. Conclusion: This review is the first to report on an EM-specific boot camp at a non-American institution, and it provides a framework for the development and refinement of pre-internship EM boot camps at other universities.

Background: Acute pain is a common presentation in the Emergency Department (ED) and inadequacy in its treatment can lengthen stay. Earlier analgesia use and discharge has been associated with positive patient experiences and improved pain management. Validated ‘fast-track pathways’ to aid physician decision making in analgesic administration is associated with decreased waiting times in renal colic diagnoses. Aim Statement: Our aim was to create an order set, for an approach to patients with acute pain, to reduce median time from point of triage to analgesia. We sought to reduce median time by 15 minutes, for ED patients with renal colic in the three months after implementation as compared to three months before. Measures & Design: We used a literature review and comparison to existing order sets at other EDs to design our draft. We focused our evaluation on patients with renal colic. We underwent multiple revisions based on stakeholder feedback and educated both physician and nursing teams about the order set. The utilization, however, was at physician discretion. We implemented the order set on March 30, 2017. After three months, an electronic retrospective chart review identified patients with a final renal colic diagnosis. For each patient, we captured triage time using electronic records and time to analgesia with the medication cart. Utilization of order sets was confirmed via manual chart audit. Evaluation/Results: A run chart showed worsening times after the intervention. Median time to analgesia in minutes, 3 months prior (n = 90) and post (n = 93) intervention, increased from 228 to 310 minutes, although the range was very large. Chart audits demonstrated a considerably low uptake of the order set with a small gradual increase from 0% to 20% over the 3-month period. Discussion/Impact: There was insufficient uptake of the Acute Pain order set preventing impact on time to analgesia. Changes in occupancy likely contributed to the worsening times. There was an increase in utilization over the 3-month period and could be due to increased awareness. This demonstrates that interventions require more than implementation to be effective. Difficulties in implementation were due to the document not being readily available. We have organized the nursing staff to attach order sets onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

Background: Understaffing in mass casualty incidents limits flow in the overwhelmed emergency department, which is further compounded by inefficient use of those same human resources. Process mapping analysis of a “Code Orange” exercise at a tertiary academic hospital exposed the failures of telephone-based emergency physician fan-out protocols to address these issues. As such, a quality improvement and patient safety initiative was undertaken to design, implement, and evaluate a new mass casualty incident fan-out mechanism. Aim Statement: By February 2019, emergency physician fan-out will be accomplished within 1 hour of Code Orange declaration, with a response rate greater than 20%. Measures & Design: Process mapping of a Code Orange simulation highlighted telephone fan-out to be ineffective in mobilizing emergency physicians to provide care in mass casualty incidents: available staff were pulled from their usual duties to help unit clerks unsuccessfully reach off-duty physicians by telephone for hours. Stakeholders subsequently identified automation and computerization as a compelling change idea. A de-novo automated bidirectional text-messaging system was thus developed. Early trials were analyzed for process measures including fan-out speed, unit clerk involvement, and physician response rate, with further large-scale tests planned for early 2019. Evaluation/Results: Only 50% of telephone fan-out was completed after a 2-hour exercise despite 3 staff supplementing the 2 on-shift unit clerks, with a 4% physician response rate. In contrast, data from initial trials of the automated system suggest that full fan-out can be performed within 1 hour of Code Orange declaration and require only 1 unit clerk, with text-messages projected to yield higher physician response rates than telephone calls. Early findings have thus far affirmed stakeholder sentiments that automating fan-out can improve speed, unit clerk efficiency, and physician response rate. Discussion/Impact: Automated text-message systems can expedite fan-out protocol in mass casualty incidents, relieve allied health staff strain, and more reliably recruit emergency physicians. Large-scale trials of the novel system are therefore planned for early 2019, with future expansion of the protocol to other medical personnel under consideration. Thus, automated text-message systems can be implemented in urban centres to improve fan-out efficiency and aid overall emergency department flow in mass casualty incidents.

Background: Chest tube insertion is a time and safety critical procedure with a significant complication rate (up to 30%). Industry routinely uses Lean and ergonomic methodology to improve systems. This process improvement study used best evidence review, small group consensus, process mapping and prototyping in order to design a lean and ergonomically mindful equipment solution. Aim Statement: By simplifying and reorganising chest tube equipment, we aim to provide users with adequate equipment, reduce equipment waste, and wasted effort locating equipment. Measures & Design: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Necessary equipment was identified. Next, two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student) to refine the equipment list and packaging. A final equipment storage system was produced and evaluated by an interprofessional team during cadaver training using a survey and Likert scales. Evaluation/Results: There were 47 equipment items in the pre-intervention ED chest tube tray. After prototyping 21 items were removed while nine critical items were added. The nine items missing from the original design were found in four different locations in the department. Six physicians and seven RNs participated in cadaver testing and completed an evaluation survey of the new layout. Participants preferred the new storage design (Likert median 5, IQR of 1) over the current storage design (median of 1, IQR of 1). Discussion/Impact: The results suggest that the lean equipment storage is preferred by ED staff compared to the current set-up, may reduce time finding missing equipment, and will reduce waste. Future simulation work will quantitatively understand compliance with safety critical steps, user stress, wasted user time and cost.

Background: In 2016 The Fraser Health Authority's Emergency Network established a priority to standardize patient access and flow through their 13 emergency departments (ED). A Model of Care (MOC) was developed after an extensive review of the literature and current practices across BC. Aim Statement: The ED Model of Care (MOC) specifies best practice expectations with respect to emergency patient access and flow. Rather than a ‘top-down’ mandate of expected practices, the MOC provided the opportunity for site-based teams to promote solutions that were ‘locally actioned and regionally enabled’. Measures & Design: ED Quality Improvement (QI) teams were developed at all sites. The ED Network developed a “QI Bootcamp”, a one-day course focused on imparting tools to drive improvements, providing a baseline understanding of how to launch and sustain local QI initiatives. Using Prosci's change approach, an emphasis was placed on using local ingenuity to implement plans, analyze feedback and diagnose gaps. This approach measured utilization of the changes to tangibly link initiatives and change to specific outcomes. As part of this strategy, an online scorecard was created to measure local results against best practice outcomes. The scorecard tracked quantitative access metrics such as ED Length of Stay (EDLOS), Left Without Being Seen rate, and triage time. Measures such as forming a QI team, identifying a QI project and completing a PDSA cycle were included in the scorecard Evaluation/Results: The MOC change management strategy was launched in May of 2018. By December 2018 all 13 EDs had formed a local QI team and identified a project. Twelve sites had completed at least one PDSA cycle and 10 sites had at least 75% of their members attend the QI Bootcamp. The scorecard displayed improvements in flow metrics. Highlights include the average arrival to triage time decreasing by 36% at one site, EDLOS for moderately ill patients decreased from 4.8 to 3.4 hours at another, and a community hospital had low acuity patient EDLOS decrease from 3.52 to 2.37 hours. Discussion/Impact: A standardized approach to patient access and flow in the ED (MOC), combined with the engaging grass roots approach to inspiring local innovation, allied with a concrete change management approach demonstrated significant results for patients accessing and moving through EDs. This pattern that is more likely to sustain itself because the results are felt and locally owned.

Background: In Alberta in 2016 more people died from an opioid overdose than from motor vehicle crashes. Naloxone is an opioid antagonist - it can reverse an opioid overdose for a period of 30 to 60 minutes. Naloxone kits are available free at emergency departments and community organizations around the province with training provided at the point of pickup. It is possible that training may be refused or may be forgotten and people are often left to rely solely on the instructions included in the kit. Human centred design can improve the way people interact with overdose instructions. Aim Statement: This study will measure the effectiveness and usefulness of prototype community naloxone kit instructions over a six month period of time (2018) in Calgary and Edmonton with the aim to use human centred design principles to improve the way people interpret emergency overdose response directions. Measures & Design: Information design experts engaged people with lived experience to provide a process map outlining the current role that educational materials and instructions for community naloxone kits play in responding to an opioid overdose. Alberta Health Services (AHS) Human Factors, in collaboration with AHS harm reduction developed the protocol and administered pre- and post-questionnaire and specific ‘performance checkpoints’ intended to measure effectiveness and usefulness. A simulated overdose including a mannequin, injection trainer and anatomical paper diagram was designed and a community naloxone kit with instructions setting was provided. Participants were recruited through harm reduction nurses with pre-existing clinical relationships (experienced group), family and friends of people who use opioids and general public (non-experienced) through the University of Alberta Faculty of Art and Design. Evaluation/Results: A total of 30 voluntary participants provided their informed consent and engaged in a simulated overdose scenario using a set of prototype instructions developed by a professional information designer. Through repeated data sampling, the following points were observed and will be integrated in the next iteration of design: It isn't clear to people what opioids are. It isn't clear to people that giving a dose of naloxone will not harm a person, especially if they have not overdosed. Almost none of the participants called 911. People seem to read pictures and text equally in the non-experienced group, but in the experienced group, typically read the pictures. Many participants stated that they knew how to do rescue breaths, but did not perform them correctly. Performing the procedure is a not the same as being asked about how to perform the procedure. Discussion/Impact: Even with new instructional prototypes, many participants identified components that were unclear or confusing. The experienced group made less mistakes than the non-experienced group. They seemed to be more invested or interested in saving a friend's life. These instructions will go through another round of design to incorporate feedback from end users. The final product will be part of a larger provincial emergency medicine initiative that includes participant led design and education around emergency response in opioid overdose settings.

Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.

Background: Most admissions to hospitals occur through the emergency department (ED). The impact of emergency physicians’ decisions to admit a patient to hospital can have wide ranging effects on health care spending, hospital congestion and patient outcomes. A growing body of evidence shows that outpatient management of conditions such as diverticulitis, heart failure and pulmonary embolism is both safe, effective and can reduce costs. Aim Statement: To support emergency staff in making safe, informed decisions to appropriately reduce admission rates without increasing the rate of patients returning and being admitted. Measures & Design: Significant variability in admission rates between emergency physicians exists and no correlation between actual and self-reported admission rates is observed. One means to change behavior is through audit and feedback, however a Cochrane review on this topic concluded that it was only effective if specific conditions were met; findings which were incorporated into this project. An audit tool was created comparing individual physicians’ admission and “bounce back” rates to their peers. The tools contained averages for the individual and site for admission and bounce back rates and were shared with physicians every 2 months. Physicians were divided into three equal groups, low, medium and high admitters and targets established. Department heads met with high admitters. Evaluation/Results: The project was started in September 2016. Admission rates in the three physician groups were compared in the ten months before September 2016 (prior) and after January 2017 (post). September to December 2016 was considered the “rollout” period and not included in the analysis. Significance was tested using a Permutation test and a p-value cut off level of 5%. Nine emergency departments took part. Seven sites experienced a significant decrease in the admission rate of top admitters, three showed a significant increase in the rate of low admitters and two showed a significant increase in the rate of medium admitters. Pooled results showed a decrease in the admission rates of the top admitters and no significant change to the medium or low admitters. Discussion/Impact: Comparing the pre- and post-periods yielded a decrease in admissions of 773 patients on an annualized basis. The impact of the change in the top five highest admitters at the biggest three hospitals estimated an annualized beds savings of 25.3 beds.

Background: Older adults in the emergency department (ED) take an increasingly larger portion of resources, have increased length of stay and a higher likelihood of adverse outcomes. In many cases bad planning, multiple vague handovers, and lack of coordinated care exacerbate this problem. With the impending onset of our aging population this is a situation that can be expected to compound in complexity in the years to come. Aim Statement: We describe daily interdisciplinary review of ED patients over the age of 75 years (or otherwise identified as a challenging discharge) to discuss barriers and facilitators to discharge/disposition. We will use data to identify the impact of this particular population to ED flow. Measures & Design: This initiative developed from our participation in the Acute Care of the Elderly (ACE) Collaborative and applies Plan/Do/Study/Act (PDSA) cycles and run reports to compare: length of stay; Identification of Seniors at Risk (ISAR) screening tool; ED census, admission/discharge rates, bounce back rates, consulting services, and interdisciplinary participation. Evaluation/Results: The average daily census of our ED between the months of July-October of 2018 was over 211 patients/day, of which over 12% were patients 75 years and older. We conducted over 70 huddles, reviewing an average of 11 patients per day. The average length of stay for patients at the time of the huddle was 19 hours, significantly higher than the general emergency population. Next day admission and discharge rates were comparable, 44.8% and 43.1% respectively with the additional patients remaining in the ED with no disposition. Internal medicine was consulted on 30% of all huddle patients and 38.4% subsequently admitted. Thirty day bounce back rates for huddle patients discharged home was 29.3%. Around 60% of patients 75 and older were screened with the ISAR and 55.7% of these were positive (2 or more questions). Discussion/Impact: Older patients consume a disproportionate amount of ED resources. Daily interdisciplinary ‘geriatric huddles’ improved communication between members of the ED team and with consulting services. The huddles enhanced awareness of the unique demands that older adults place on the flow of the ED, and identified opportunities to enhance patient flow.

Introduction: Delirium is a frequent pathology in the elderly presenting to the emergency department (ED) and is seldom recognised. This condition is associated with many medical complications and has been shown to increase the hospital length-of-stay. The objective of this study was to identify the predictor factors of developing delirium in this high-risk population. Methods: Design: This study was part of the multicenter prospective cohort INDEED study. Participants: Patients aged 65 and older, initially free of delirium and with an ED stay of 8h or longer, were followed up to 24h after ward admission. Measures: Clinical and demographic variables were collected by interview and chart review. A research professional assessed their delirium status twice daily using the Confusion Assessment Method (CAM). Analyses: A classification tree was used to select predictors and cut-points that minimized classification error of patients with incident delirium. After literature review, nineteen predictors were considered for inclusion in the model (eight non-modifiable and eleven modifiable factors). Results: Among the 605 patients included in this study, incident delirium was detected by the CAM in 69 patients (11.4%). In total, fourteen variables were included in a preliminary model, of which six were intrinsic to the patient and eight were modifiable in the ED. Variables with the greatest impact in the prediction of delirium includes age, cognitive status, ED length of stay, autonomy in daily activities, fragility and mobility during their hospital stay. The diagnostic performance of the model applied to the study sample gave a sensitivity of 78.3% (95% CI: 66.7 to 87.3), a specificity of 100.0% (95% CI: 99.3 to 100.0), a PPV of 100.0% (95% CI: 93.4 to 100.0) and a NPV of 97.3% (95% CI: 95.6 to 98.5). Conclusion: The delirium risk model developed in this study shows promising results with elevated sensitivity and specificity values. Considering the limited ability to predict and detect delirium among physicians, the potential increase in sensitivity provided by this tool could be beneficial to patients. This model will ultimately serve to identify high-risk patients with the goal of developing strategies to alter modifiable risk factors and subsequently decrease the incidence of delirium in this population.

Introduction: This systematic scoping review aims to synthetize the available evidence on the epidemiology, risk factors, clinical characteristics, screening tools, prevention strategies, interventions and knowledge of health care providers regarding elder abuse in the emergency department (ED). Methods: A systematic literature search was performed using three databases (Medline, Embase and Cochrane Library). Grey literature was scrutinized. Studies were considered eligible when they were observational studies or randomized control trials reporting on elder abuse in the prehospital and/or ED setting. Data extraction was performed independently by two researchers and a qualitative approach was used to synthetize the findings. Results: A total of 443 citations were retrieved from which 58 studies published between 1988 and 2018 were finally included. Prevalence of elder abuse following an ED visit varied between 0.01% and 0.03%. Reporting of elder abuse to proper law authorities by ED physicians varied between 2% to 50% of suspected cases. The most common reported type of elder abuse detected was neglect followed by physical abuse. Female gender was the most consistent factor associated with elder abuse. Cognitive impairment, behavioral problems and psychiatric disorder of the patient or the caregiver were also associated with physical abuse and neglect as well as more frequent ED consultations. Several screening tools have been proposed, but ED-based validation is lacking. Literature on prehospital- or ED-initiated prevention and interventions was scarce without any controlled trial. Health care providers were poorly trained to detect and care for older adults who are suspected of being a victim of elder abuse. Conclusion: Elder abuse in the ED is an understudied topic. It remains underrecognized and underreported with ED prevalence rates lower than those in community-dwelling older adults. Health care providers reported lacking appropriate training and knowledge with regards to elder abuse. Dedicated ED studies are required.

Introduction: It is recommended that seniors consulting to the Emergency Department (ED) undergo a comprehensive geriatric screening, which is difficult for most EDs. Patient self-assessment using electronic tablet could be an interesting solution to this issue. However, the acceptability of self-assessment by older ED patients remains unknown. Assessing acceptability is a fundamental step in evaluating new interventions. The main objective of this project is to compare the acceptability of older patient self-assessment in the ED to that of a standard assessment made by a professional, according to seniors and their caregivers. Methods: Design: This randomized crossover design cohort study took place between May and July 2018. Participants: 1) Patients aged ≥65 years consulting to the ED, 2) their caregiver, when present. Measurements: Patients performed self-assessment of their frailty, cognitive and functional status using an electronic tablet. Acceptability was measured using the Treatment Acceptability and Preferences (TAP) questionnaires. Analyses: Descriptive analyses were performed for sociodemographic variables. Scores were adjusted for confounding variables using multivariate linear regression. Thematic content analysis was performed by two independent analysts for qualitative data collected in the TAP's open-ended question. Results: A total of 67 patients were included in this study. Mean age was 75.5 ± 8.0 and 55.2% of participants were women. Adjusted mean TAP scores for RA evaluation and patient self-assessment were 2.36 and 2.20, respectively. We found no difference between the two types of evaluations (p = 0.0831). When patients are stratified by age groups, patients aged 85 and over (n = 11) showed a difference between the TAPs scores, 2.27 for RA evaluation and 1.72 for patient self-assessment (p = 0.0053). Our qualitative data shows that this might be attributed to the use of technology, rather than to the self-assessment itself. Data from 9 caregivers showed a 2.42 mean TAP score for RA evaluation and 2.44 for self-assessment. However, this relatively small sample size prevented us to perform statistical tests. Conclusion: Our results show that older patients find self-assessment in the ED using an electronic tablet just as acceptable as a standard evaluation by a professional.

Introduction: Opioid side effects are common when treating chronic pain. However, the rate of opioid side effects for acute pain has rarely been examined, particularly in the post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid induced side effects (constipation, nausea/vomiting, dizziness, and drowsiness) in patients discharged from the ED with an opioid prescription. Methods: This was a prospective cohort study of patients aged ≥18 years that visited the ED for an acute pain condition (≤ 2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects. Results: Mean age of the 386 patients included was 55 ± 16 years; 50% were women. During the 2-week follow-up, 80% of patients consumed at least one dose of opioids. Among the patients who used opioids, 38% (95%CI: 33-48) reported constipation, 27% (95%CI:22-32) nausea/vomiting, 30% (95%CI:25-35) dizziness, 51% (95%CI:45-57) drowsiness, and 77% (95%CI:72-82) reported any side effects. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report any side effect (OR 7.5, 95%CI:4.3-13.3) and constipation (OR 7.5, 95%CI:3.1-17.9). A significant dose response effect was observed for constipation but not for the other side effects. Nausea/vomiting (OR 2.0, 95%CI:1.1-3.6) and dizziness (OR 1.9, 95%CI:1.1-3.4) were associated with oxycodone compared to morphine. Conclusion: Similar to chronic pain, opioid side effects are highly prevalent during short-term treatment for acute pain. Physicians should be aware and inform patients about those side effects.

Introduction: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED) and is associated with an increased risk of ischemic stroke. Studies have shown that only oral anticoagulant (OAC) therapy reduces risk of AF related stroke. Our objective was to measure the prescribing practices for OACs for new onset AF at a tertiary ED and two surrounding community EDs, and identify rates of adverse effects within 90 days. The findings of this study will provide quality assurance information for the management of patients with new onset AF. This information has the potential to promote adherence to prescribing guidelines for AF in the ED and the reduction of common adverse events such as ischemic stroke. Methods: We conducted a retrospective chart review of 385 patients with new onset AF who presented to the ED between November 2014 to Mach 2018. We defined new onset as symptoms <48 hours and had AF confirmed with electrocardiogram. We recorded the selected therapy choice of cardioversion and/or rate control, gender, age, and assessed CHADS-65 score. We recorded who was prescribed OAC and those who were referred to cardiology, family medicine, or did not have a documented follow up plan. Patients with a previous history of AF or current anticoagulant therapy were excluded. We recorded if any patients returned to the ED within 90 days with ischemic stroke, AF recurrence, myocardial infarction, other embolic disease or death. Results: 86 of 294 (29.5%) of patients who qualified under CHADS-65 received OACs appropriately. 64 of 66 (97.0%) of patients who did not qualify under CHADS-65 did not receive OACs appropriately. 5 patients overall returned within 90 days with ischemic stroke, 4 of those were not prescribed OACs, however this was not statistically significant (P = 0.999). Conclusion: This data suggests that physicians in the study are under-prescribing OACs relative to published guidelines. A larger study is necessary to elucidate the effect of ED OAC prescribing patterns on long-term patient outcome.

Introduction: Patients with Chronic Obstructive Pulmonary Disease (COPD) often present to the ED with acute exacerbations (AE-COPD) of the disease. A potential occult yet fatal disease that might contribute or accompany an AE-COPD presentation is a pulmonary embolism (PE). Previous studies have investigated and report rates of PE in up to 29% of patients presenting with AE-COPD. Misdiagnoses of PE leads to poor outcomes, however, over-testing for PE also presents with substantial risks to the patient and strain on acute care resources. The goal of this study was to pragmatically identify the prevalence and 30-day incidence of PE in patients presenting with AE-COPD to EDs, as well as the burden and yield of PE investigations. Methods: We conducted a retrospective analysis of extracted data for patients □50 years old presenting to one of four emergency departments in Calgary with an AE-COPD since 2013. Patients with a history of outpatient anticoagulation therapy from a community pharmacy were excluded. Each patient chart was reviewed to identify a diagnosis of PE during the admission for an AE-COPD, or 30 days post discharge from an AE-COPD admission or ED presentation. An AE-COPD diagnosis was defined as a primary. Results: A total of 9554 AE-COPD ED patient visits were included in the study. 0.69% (95%CI 0.54 to 0.88) were identified to have a PE. 26 of the 66 (39.4%) were diagnosed during an AE-COPD inpatient admission, while 43 (65.2%) were diagnosed within 30 days post-discharge from an AE-COPD admission or ED presentation. Since 2016, 7.4% of AE-COPD patients underwent a CT-PE, while 16.7% underwent a d-dimer. The most common chief complaint in PE patients was dyspnea (75.8%). The mean age of the PE diagnosed was 73.4, with nearly equal representation of both sexes. Many patients had underlying comorbidities, such as hypertension, diabetes, and cancer of various sites, all of which are risk factors for developing a PE. Conclusion: The prevalence and 30-day incidence of PE in AE-COPD patients appears to be lower than what was previously reported in the literature. Despite this, a significant proportion of AE-COPD patients were exposed to the risks and burden of a PE work up, with low diagnostic yield. PE investigations in AE-COPD should be used selectively and could inform a quality improvement indicator. A future prospective study would drastically contribute to whether a PE clinical work up should be recommended and of value to patients.

Introduction: Recently there have been many studies performed on the effectiveness of implementing LEAN principals to improve wait times for emergency departments (EDs), but there have been relatively few studies on implementing these concepts on length of stay (LOS) in the ED. This research aims to explore the initial feasibility of applying the LEAN model to length-of-stay metrics in an ED by identifying areas of non-value added time for patients staying in the ED. Methods: In this project we used a sample of 10,000 ED visits at the Health Science Centre in St. John's over a 1-year period and compared patients’ LOS in the ED on four criteria: day of the week, hour of presentation, whether laboratory tests were ordered, and whether diagnostic imaging was ordered. Two sets of analyses were then performed. First a two-sided Wilcoxon rank-sum test was used to evaluate whether ordering either lab tests or diagnostic imaging affected LOS. Second a generalized linear model (GLM) was created using a 10-fold cross-validation with a LASSO operator to analyze the effect size and significance of each of the four criteria on LOS. Additionally, a post-test analysis of the GLM was performed on a second sample of 10,000 ED visits in the same 1-year period to assess its predictive power and infer the degree to which a patient's LOS is determined by the four criteria. Results: For the Wilcoxon rank-sum test there was no significant difference in LOS for patients who were ordered diagnostic imaging compared to those who were not (p = 0.6998) but there was a statistically significant decrease in LOS for patients who were ordered lab tests compared to those who were not (p = 2.696 x 10-10). When assessing the GLM there were two significant takeaways: ordering lab tests reduced LOS (95% CI = 42.953 - 68.173min reduction), and arriving at the ED on Thursday increased LOS significantly (95% CI = 6.846 – 52.002min increase). Conclusion: This preliminary analysis identified several factors that increased patients’ LOS in the ED, which would be suitable for potential LEAN interventions. The increase in LOS for both patients who are not ordered lab tests and who visit the ED on Thursday warrant further investigation to identify causal factors. Finally, while this analysis revealed several actionable criteria for improving ED LOS the relatively low predictive power of the final GLM in the post-test analysis (R2 = 0.00363) indicates there are more criteria that influence LOS for exploration in future analyses.

Introduction: Pulmonary embolism (PE) is a treatable condition, with a low mortality rate (of around 1% in those who are diagnosed with the condition). The risk of recurrent PE is well managed with long term anticoagulation. Past literature suggests that patients who are diagnosed with PE can go on to experience existential anxiety and symptoms suggestive of post-traumatic stress disorder (PTSD). This study aimed to evaluate the mental and emotional experiences of PE patients through the lens of PTSD, and the factors involved in psychological distress following a PE diagnosis. Methods: Semi-structured interviews were conducted with PE patients at the Juravinski Hospital thrombosis clinic in Hamilton, Ontario. Interview questions were based on DSM-5 criteria of PTSD and relevant existing literature. The transcripts were analyzed by two researchers based on an approach that considers both the content of patients’ accounts as well as the way that patients choose to interpret and deliver those accounts, to develop major themes associated with psychological distress. Results: A total of 37 patients, ranging from 28 to 85 years of age, were interviewed. The patients’ accounts suggested that the manner in which a PE diagnosis was delivered by an emergency physician was a significant factor in the degree to which they experienced psychological distress. For example, patients reported focusing on words suggesting that they were ‘a ticking time-bomb’ or that ‘a lot of people don't get through this,’ which introduced a degree of panic. A number of patients continued to focus on these words, months or years after their diagnosis. Some feared that they could have recurrent PE which could lead to death. Diagnoses that were delivered calmly with thorough explanations of why a patient experienced PE-related symptoms and how they will be treated, helped to minimize any subsequent anxiety. Patients initially misdiagnosed with an alternative condition in the ED also expressed feelings of anxiety and distress. The presence of physically and mentally distressing symptoms was also a factor which contributed to mental distress and anxiety regarding a PE recurrence. Conclusion: Caution should be taken in the delivery of PE diagnosis in the emergency department. Over-emphasis on the severity and life-threatening nature of PE should be avoided to reduce psychological distress.

Introduction: GridlockED is an educational (or “serious”) game recently developed by a team at McMaster to teach medical learners about patient flow in the emergency department (ED). Beyond patient flow, we were cognizant that the game could provide additional learning opportunities for learners. The goal of this program evaluation project was to investigate workshop attendees’ experiences and identify what areas they found most educational. Methods: A GridlockED board game workshop was developed and delivered in several locations over the fall of 2018. Workshops targeted medical learners and were organized by local emergency medicine interest groups. After a standardized video-based introduction to the game concept and rules, the learners played GridlockED for approximately 90 minutes. After the play session, learners completed an anonymous survey consisting of 7-point Likert scale questions about their experience. They were also asked to identify the learning domains for which GridlockED was developed (Patient Flow, Communication and Teamwork, and ED Basics), and were asked via free-text to identify learning objectives from their experience. We received an exemption for this study from our institutional review board. Results: We had 25 respondents (24 medical students and 1 resident). Trainees rated GridlockED as both enjoyable to play and as a meaningful educational experience, with an average rating of 6.56 (SD 0.94) for enjoyability and 6.44 (0.92) for education. When asked what targeted learning domain was most helpful, 45% of students identified patient flow, 37% teamwork and communication, and only 18% ED basics. When asked to identify their top three areas of learning in open-ended responses, students actually identified resource management most frequently (48%), with improved communication skills (40%) as the second most prominent learning objective. Other interesting self-identified learning points were: a greater appreciation of the role of various providers (24%), the unpredictability of ED care (12%), and how things can go wrong (12%). Conclusion: Medical learners find GridlockED to be both enjoyable and educational. In our targeted areas of learning they found patient flow to be the most educational, but self-identified multiple other areas for learning. Students identified resource management and communication as key areas of learning, suggesting that future workshops might be designed specifically to teach these skills.

Introduction: In order to better characterize procedural skills curricula in Canada, a national survey was conducted. The objectives of the survey were: (i) to characterize procedural skills education currently employed in pre-clerkship and clerkship curricula; (ii) to determine what skills physician-educators think medical students should know upon graduation; and (iii) to identify physician-educator perceptions regarding the development of pre-clerkship procedural curriculum. Methods: A web-based survey was distributed to 201 clinician-educators across Canada's 17 medical schools. Respondents were directed to an individualized survey based on their self-identified roles at their institution. Respondents were asked demographic questions, what procedural skills are being taught and in what setting at their institution, and their opinions on the value of a pre-clerkship procedural curriculum. Results: From the 17 school's surveyed, 12 schools responded, with 8 schools responding “yes” that they had a clerkship procedural curriculum. For a pre-clerkship procedural curriculum, only 4 schools responded “yes”. The 5 of the top 10 procedurals skills identified that medical students should know upon graduation, in order, are: IV Access, Airway Management/Ventilator Management, Local anesthesia/field block, Casting, Spontaneous Vaginal Delivery. On a Likert scale, clinician-educators strongly supported a pre-clerkship procedural curriculum (median = 4.00/5.00, mode = 5.00/5.00), and they believed it would decrease anxiety (median = 4.00/5.00), increase confidence (median = 4.00/5.00), and increase technical ability (median = 3.00/5.00) in incoming clerks. Conclusion: Across Canada, the state of undergraduate medical education procedural skills education is inconsistent. With the identification of the Top 10 procedural skills medical students should know upon graduation, the learning objectives of a formal curriculum can be developed. With overwhelming support from physician-educators, a formal pre-clerkship procedural curriculum is poised to redefine the landscape of procedural care for a whole new generation of physicians.