Introduction: Pre-hospital telecommunication (patches) requires a special type of conversation. Receiving and processing correct information is critical when making clinical decisions, such as a termination of resuscitation (ToR). In a study of radio patches, a common patch structure emerged from the data analysis. Use of this standard structure resulted in shorter and less confusing patches. We sought to understand patch structure to be able to target interventions to improve the quality and efficiency of communication needed for critical clinical decisions. Methods: We undertook a retrospective analysis of all ToR patches between physicians and paramedics from 4 paramedic services, recorded by the Ambulance Dispatch Centre between Jan 01-Dec 31, 2014. Four services used Primary Care Paramedics and 1 service also used Advanced Care Paramedics. MP3 patch recording files were anonymized, transcribed, and read multiple times by the authors. Transcripts were coded and analyzed using mixed methods-quantitative descriptive statistics and qualitative thematic framework analysis. Results: The data set was 127 ToR patches-466 pages of transcripts. 116 patches (91.3%) had a standard structure (SS): participant introduction, clinical data presentation, clarification of data, making the decision, exchange of administrative information, and sign off. Paramedics used a mean of 81 words (95CI 74,88) to present the ‘clinical data’. Enough data was presented to meet ToR rule criteria in 52 cases (44.8%). Before making a decision to terminate resuscitation, physicians sought clarification in 100 cases (78.7%). After making the ToR decision, some physicians needed to justify their decision by seeking more data in 17 cases (13.4%). Exchange of non-clinical information (numbers, times, name spellings) took a mean of 200 words (95CI 172,228) and averaged 84 seconds or 35% of the average patch time. SS patches used a mean of 558 words, and lasted 234 sec (95CI 215,252). Non-SS patches used a mean of 654 words and lasted 286 sec (95CI 240,332). Conclusion: The most common patch structure consisted of participant introduction, data presentation, clarification of data, making the clinical decision, exchange of administrative information, and a sign off. Deviation from this SS resulted in longer patches. When a non-SS patch structure was used, the patching paramedic was tied up 25% longer and unavailable to provide patient care.

Introduction: Approximately 15 years ago cell phones replaced portable VHF radios as the means of communication between paramedics and base hospital physicians. Cellphones, like VHF radio, do not allow voice transmission and reception to occur simultaneously. Radio use requires a learned technique to signal the end of each speaker’s turn talking. These techniques are not used in normal cellphone conversation. Poor cellphone reception and poor technique result in breakdowns in communication. The literature about paramedic-physician telecommunication is almost nonexistent. There is an extensive literature in other industries, such as aviation, concerning problems in radio communication. This literature predicts that communication breakdowns are common and have critical consequences. We sought to determine how frequently problems attributable to cell phone technology arose in paramedic-physician communication. Methods: We conducted a retrospective analysis of all patch calls between physicians and paramedics from 4 municipal paramedic services from January 01-December 31, 2014. MP3 audio files, recorded during normal operating procedures by the Central Ambulance Communication Centre, were anonymized and transcribed. Transcripts were read multiple times by the authors and analyzed using mixed methods-qualitative thematic framework analysis and quantitative descriptive statistics. Results: 161 calls were identified. 155 tapes were usable for analysis. 127 (81.9%) patches involved termination of resuscitation orders, 28 (19.1%) were for advice or other orders. The data set consisted of 567 pages of transcripts. Communication problems were identified in 138 (89.0%) patches. Most had multiple problems. Technical problems included disconnections (13.5%), or difficulty hearing (56.8%)-indicated by phrases such as “what?”, “I can’t hear you”. Disorganized cell phone technique was common-individuals interrupted each other (34.2%), and talked simultaneously (54.8%). Signalling the end of “talk turns”-using terms such as “10-4” or “over”-was never used. Conclusion: In addition to technical problems (poor transmission, disconnections), disorganized cell phone ‘technique’ caused a high incidence of communication problems. This is concerning because critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Understanding the limitations of cellphone technology might improve communication.

Introduction: Frailty is associated with functional decline and physiological impairments in seniors with minor injuries. Serum biomarkers have also been suggested as potential markers of these impairments in clinical studies. However, no study has addressed the usefulness of serum biomarkers among pre-frail seniors consulting emergency departments (ED) in order to detect these impairments.Objectives: The purpose of the present study was to explore the association between several serum biomarkers and the frailty status of seniors seen in ED for a minor injury who are at risk of functional decline and 2) assist professionals in clinical decisions while identifying frail seniors in whom interventions should be started in order to prevent potential functional decline. Methods: This cross-sectional study includes 190 seniors retrieved from the larger CETI cohort and discharged home from 4 EDs after treatment of minor injuries. Their frailty status was measured by the Canadian Study of Health & Aging-Clinical Frailty Scale (CSHA-CFS). Then, patients were classified as “Robust” (CHSA-CFS levels 1 and 2) vs. “Pre-frail/Frail” (CHSA-CFS levels ≥3). Biomarkers (Albumin, Creatinine, C-reactive protein (CRP), Vitamin D, Ferritin, Glucose and Insulin-Growth Factor (IGF-1)) were obtained from blood samples. “Normal” vs. “Impaired” (low and/or high) clinical threshold values were used for statistical analyses. Results: The proportion of patients with clinically high creatinine levels (>105 µmol/L for male and >85 µmol/L for female) was higher in Pre-frails/Frails when compared to Robusts (P-value=0.01). Also, regarding IGF-1, we observed that the proportion of patients with lower IGF-1 levels (<50 µg/L) was higher in patients showing Pre-frail/Frail status (P-value=0.01). Finally, a significant correlation was found between frailty status and blood glucose (r=0.22; P-value=0.02) whereas a tendency was noted for CRP level (r=0.14; P-value=0.1). Conclusion: When compared to Robust seniors, Pre-frail/Frail individuals presenting to EDs tend to have physiological dysregulations that may help detect pre-frail status in community-dwellers. Larger prospective studies are needed to specify the usefulness and clinical implications of frailty biomarkers in the continuum of acute elder care.

Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.

Introduction: Trauma remains the primary cause of death in people under 40 in Québec. Although trauma care has dramatically improved in the last decade, no empirical data on the effectiveness of trauma care in rural Québec are available. This study aims to establish a portrait of trauma and trauma-related mortality in rural versus urban pre-hospital and hospital settings. Methods: Data for all trauma victims treated in the 26 rural hospitals and 32 Level-1 and Level-2 urban trauma centres was obtained from Québec’s trauma registry (2009-2013). Rural hospitals were located in rural small towns (Statistics Canada definition), provided 24/7 physician coverage and admission capabilities. Study population was trauma patients who accessed eligible hospitals. Transferred patients were excluded. Descriptive statistics were used to compare rural with urban trauma case frequency, severity and mortality and descriptive data collected on emergency department (ED) characteristics. Using logistic regression analysis we compared rural to urban in-hospital mortality (pre-admission and during ED stay), adjusting for age, sex, severity (ISS), injury type and mode of transport. Results: Rural hospitals (N=26) received on average 490 000 ED visits per year and urban trauma centres (N=32), 1 550 000. Most rural hospitals had 24/7 coverage and diagnostic equipment e.g. CT scanners (74 %), intensive care units (78 %) and general surgical services (78 %), but little access to other consultants. About 40% of rural hospitals were more than 300 km from a Level-1 or Level-2 trauma centre. Of the 72 699 trauma cases, 4703 (6.5%) were treated in rural and 67 996 (93.5%) in urban hospitals. Rural versus urban case severity was similar: ISS rural: 8.6 (7.1), ISS urban: 7.2 (7.2). Trauma mortality was higher in rural than urban pre-hospital settings: 7.5% vs 2.6%. Reliable pre-hospital times were available for only a third of eligible cases. Rural mortality was significantly higher than urban mortality during ED stays (OR (95% IC): 2.14 (1.61-2.85)) but not after admission (OR (95% IC): 0.87 (0.74-1.02)). Conclusion: Rural hospitals treat equally severe trauma cases as do urban trauma centres but with fewer resources. The higher pre-hospital and in-ED mortality is of grave concern. Longer rural transport times may be a factor. Lack of reliable pre-hospital times precluded further analysis.

Introduction: Patients with mild traumatic brain injury (mTBI) often present to the emergency department (ED). Incorrect diagnosis may delay appropriate treatment and recommendations for these patients, prolonging recovery. Notable proportions of missed mTBI diagnosis have been documented in children and athletes, while diagnosis of mTBI has not been examined in the general adult population. Methods: A prospective cohort study was conducted in one academic (site 1) and two non-academic (sites 2 and 3) EDs in Edmonton, Canada. On-site research assistants enrolled adult (>17 years) patients presenting within 72 hours of the injury event with clinical signs of mTBI and Glasgow comma scale score ≥13. Patient demographics, injury characteristics, and ED flow information were collected by chart review. Physician-administered questionnaires and patient interviews documented the recommendations given by emergency physicians at discharge. Bi-variable comparisons are reported using Pearson’s chi-square tests, Student’s t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, 130/250 enrolled patients were female, and the median age was 35. Proportions of successfully diagnosed mTBI varied significantly across study sites (Site 1: 89%; Site 2: 73%, Site 3: 53%; p>0.001). Patients without a diagnosis were less likely to receive a recommendation to follow-up with their family physician (OR=0.08; 95% CI: 0.03, 0.21) or advice about return to work (OR=0.17; 95% CI: 0.08, 0.04) or physical activity (OR=0.08; 95% CI: 0.04, 0.17). Patients with missed diagnoses had longer ED stays (median=5.0 hours; IQR: 3.8, 7.0) compared with diagnosed mTBI patients (median=3.9 hours; IQR: 3.0, 5.3). In the adjusted model, patients presenting to non-academic centers had reduced likelihood of mTBI diagnosis (Site 2: OR=0.21; 95% CI: 0.08, 0.58; Site 3: OR=0.07; 95% CI: 0.02, 0.24). Conclusion: The diagnostic accuracy of physicians assessing patients presenting with symptoms of mTBIs to these three EDs is suboptimal. The rates of missed diagnosis vary among EDs and were associated with length of ED stay. Closer examination of institutional factors, including diagnosis processes and personnel factors such as physician training, is needed to identify effective strategies to heighten the awareness of mTBI presentations.

Introduction: Patient co-morbidities contribute to survivability from out-of-hospital sudden cardiac arrest. Many studies have been conducted regarding contributing factors to sudden cardiac arrest survival, though very few studies have been published detailing specific analysis of morbid obesity association with return of spontaneous circulation (ROSC) in adults treated by paramedics. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Due to an increasing prevalence of morbid obesity in the United States adult population, a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was initiated in June 2016. As exact body weight is logistically difficult to obtain in the EMS care environment, a paramedic-estimated weight at the time of resuscitation to be 100 kg or greater was deemed representative of “morbid obesity” for this analysis. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT, Physio-Control Corporation, Redmond, WA). ROSC was determined from both paramedic and hospital clinician EMRs reviewed by a paramedic researcher. Results: During the 5 month study period, paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 49/90 (54.4%) with weight <100 kg as estimated by paramedics at the time of resuscitative care achieved at least transient ROSC. Only 17/43 (39.5%) with estimated weight ≥100 kg achieved any ROSC, despite paramedics authorized to perform defibrillations at higher joule energy settings for such weight. The OR for ROSC if <100 kg estimated weight is 1.83 (95% CI 0.87-3.83), though given limited sample size p=0.11. Conclusion: While survival from out-of-hospital sudden cardiac arrest in adults is multi-factorial, the presence of morbid obesity, defined as estimated weight ≥100 kg, trends towards less ROSC. Continued community health efforts to decrease the prevalence of morbid obesity in the adult population may confer improved ability to survive out-of-hospital sudden cardiac arrest.

Introduction: Emergency Medical Services (EMS) care confers distinct impact upon survivability from sudden cardiac arrest. Many studies have been conducted regarding EMS interventions for cardiac arrest, though fewer studies have been published detailing specific analysis of paramedic compliance with standing orders, particularly those involving a novel energy strategy in defibrillation. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Education on a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was delivered in classroom and internet-accessed settings. Paramedics then performed hands-on practice in DSED. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT™, Physio-Control Corporation, Redmond, WA). All ECGs and defibrillation events were reviewed by an emergency physician to determine energy settings used by paramedics for determining the accuracy of compliance with protocol-based standing orders. Results: During the 5 month study period, the paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 76/90 (84.4%) with estimated weight <100 kg were treated with correct joule settings, though only 7/43 (16.3%) with estimated weight ≥100kg received all defibrillations at 360J as protocol-specified. 26/44 (59.1%) in refractory ventricular fibrillation, defined as requiring a fourth defibrillation, received DSED as protocol-specified. Conclusion: Paramedics, when specifically trained on a novel defibrillation strategy, involving both weight-based joule settings and use of DSED for refractory ventricular fibrillation, are inconsistently able to quickly and successfully incorporate that strategy in EMS resuscitation care. Further educational endeavours are warranted to achieve higher defibrillation strategy protocol compliance.

Introduction: Included in the first list of recommendations from the Choosing Wisely Canada (CW) Emergency Medicine (EM) group was to avoid ordering lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. It has been suggested that these lumbosacral radiographs lead to unnecessary ionizing radiation and increase emergency department (ED) wait times without improving patient outcomes. This study evaluates lumbosacral imaging practices of emergency physicians (EPs) in four urban EDs. Methods: Data was retrospectively collected from patients, ages 18-60 and CTAS codes 2-5, who presented with non-traumatic LBP from April 1, 2014 to March 31, 2016 to four urban EDs. The time frame included both pre- and post-CW recommendation. Patients considered high risk, specifically with PTT >40 s or INR >1.2 s, neurology/neurosurgery/spine consults, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish lumbosacral radiograph usage rates for non-traumatic LBP. The secondary outcome was to identify factors that influenced lumbosacral spine imaging. Factors analyzed included patient age, patient sex, ED wait times, physician age, physician experience, and physician sex. Statistical significance was determined by chi-squared analysis. Results: The data from 3140 low-risk patients showed that 16.5% of the patients received lumbosacral radiographs. Physician variation in X-ray ordering was 0% to 85.7% (IQR 4.6 to 25%). There was a significant difference between the X-rays ordered at each site (site 1 (23.1%)>site 2 (17.2%)>site 3 (14.9%)>site 4 (11.3%), p<0.001). CCFP-EM licensed physicians (17.9%) ordered more X-rays compared to licensed physicians (13.7%, p<0.001). Time of presentation, physician sex, and patient sex did not affect the imaging practices. There was a trend towards decreased ordering of X-rays (17.6% vs. 15.1%, p=0.06) post-CW recommendation. Conclusion: Considerable variation exists in the ordering practices of Calgary EPs; however, on average they are choosing wisely in terms of ordering imaging for non-traumatic LBP.

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.

Introduction: Between June 15 and Aug 31st 2014, Canada’s Northwest Territories (pop 44,000: Stats Can), a subarctic region which is over 2°C warmer than it was in the 1950’s, experienced an unprecedented number of forest fires, with 385 fires and approximately 3.4 million hectares of forest affected. This resulted in one of Canada’s most severe and prolonged urban smoke exposures for the capital city of Yellowknife and surrounding Aboriginal communities. Our objective was to obtain a big-picture sense of the health impact of the Summer of Smoke on the population of these communities through a mixture of quantitative and qualitative analysis. Methods: We analyzed PM2.5 levels, salbutamol dispensations, clinic and hospital cardiorespiratory variables, and in-depth video interviews with community members from Yellowknife, N’Dilo, Dettah and Kakisa. Results: 49% of days June15-Aug31 in 2014 had a PM2.5 over 30 mcg/m3, as compared to 3% in 2012 and 9% in 2013 and 2015. Max daily PM 2.5 in 2014 was 320.4 mcg/m3. There was a 22% increase in outpatient salbutamol dispensations in 2014 compared to the average of 2012, 2013 and 2015. More cough, pneumonia and asthma were seen in clinics compared to 2012-2015 (P<0.001). There was a 42% increase in respiratory ER visits in 2014 compared to 2012-13, but no change in cardiac variables. The respiratory effect was most pronounced in children 0-4 (114% increase in ER visits). Qualitative analysis demonstrates themes of fear, isolation, lack of physical activity, alteration of traditional summertime activities for both aboriginal and non-aboriginal subjects, elements of resilience and expectation for future smoky summers in the context of a changing climate. Conclusion: Prolonged wildfire seasons have a profound effect on overall wellbeing. Responses to help minimize mental and physical impacts such as the creation of clean-air community shelters, recreation programming, initiatives to support community cohesion, and “go outside when it is not smoky” messaging require further study.

Introduction: The first-ever EM postgraduate training program in Ethiopia was launched at Addis Ababa University in 2010. EM faculty from the University of Toronto were invited to design and implement an EM rotation-based curriculum with tri-annual teaching trips to support the overall AAU EM program. To date, three cohorts of EM specialists (n=15) have graduated from the three-year program. After six years of implementation, we undertook a qualitative evaluation of the TAAAC-EM curriculum. Methods: Data collection took place in 2016 in Ethiopia via in-person graduate interviews (n=12). Participants were interviewed by a trained research assistant who used a semi-structured interview guide. Standard interview, transcription and analysis protocols were utilized. Qualitative software (QSR-NVIVO 9) was used for thematic grouping and analysis. Results: Graduates of AAU’s EM residency training program reported very positive experiences with the TAAAC-EM curriculum overall. All graduates acknowledged the positive impact of TAAAC-EM’s emphasis on bedside teaching, a unique component of the TAAAC-EM model compared to traditional teaching methods at AAU. Graduates felt that TAAAC-EM teachers were effective in creating a novel culture of EM at AAU and in role-modeling ethical, evidence-based EM practice. When asked about specific areas for program improvement, the following themes emerged: 1) a desire to shift delivery of the didactic clinical epidemiology curriculum to the senior residency years (PGY2-3) to coincide with completion of a required residency research project; 2) a desire for increased simulation and procedural teaching sessions and 3) the need for more nuanced context specificity in the curriculum delivery to incorporate local guidelines and practice patterns. A lack of educational supports during non-TAAAC-EM visits was also identified as an area for further work. Conclusion: Interviewing graduates of AAU’s EM residency training program proved important for determining areas of curriculum improvement for future trainees. It also provided critical input to TAAAC-EM strategic planning discussions as the partnership considers expanding its scope beyond Addis Ababa.

Introduction/Innovation Concept: Medical simulation is becoming increasingly useful for healthcare education. Simulation-based crisis resource management (CRM) has been shown to produce improvements in skill acquisition, communication and team behaviors. Simulation has become a key component of most Family Practice (FP) residency programs and many programs are moving towards developing formal simulation curriculums. The Coastal FP Residency is a relatively new and unique program with a large emphasis on rural medicine. Graduates have gone on to practice in remote areas with less access to supports for critically ill patients. Therefore, an effective simulation curriculum, focused on Emergency Medicine, is of great importance to this program. Methods: To develop our curriculum, Kern’s framework for medical education was selected given its prior success in similar endeavors. The first step of this approach involves a needs assessment, which we accomplished in the form of an online survey. The questionnaire included pre-defined topics pertaining to the training needs of FP Residents destined for Rural Practice with respect to technical skills, CRM skills, specific medical conditions and categories of medical conditions. Classification of answers included multiple choice, 5-point Likert scales as well as an option for free-text answers. The survey was distributed to pre-identified participants including stakeholders/educators within the Coastal FP residency program as well as simulation education leads for FP residencies throughout British Columbia (BC). Current residents, as well as program graduates were also asked to complete the survey. Curriculum, Tool, or Material: The results of this survey were used to develop formal goals and objectives which were in turn used to write or adapt 24 cases for the curriculum. Cases from categories (e.g. Pediatrics) rated as “Extremely Important” on the Likert scale were included proportionally more in the curriculum. The cases were also designed to assess/practice a higher proportion of CRM elements considered important and to address commonly identified difficulties in resuscitation. Cases were developed, where possible, using local or national guidelines and are currently in the stage of peer review (by a minimum of two peers). Conclusion: The curriculum will be implemented in July 2017 and we will transition towards the evaluation phase. Our goal is to develop and distribute formalized needs assessments to rural FP residencies across BC so that they may develop dynamic, formal curriculums of their own.

Introduction/Innovation Concept: There is a paucity of peer-reviewed works investigating the History of Emergency Medicine (EM) in Canada, and none examining a single centre. This study analyzed the academic and clinical evolution of EM in the City of Ottawa from its origins to present. Methods: The study comprised primary and secondary historical research and an oral history methodology. A literature review was performed on the following databases: PubMed, Medline, EMBASE, JSTOR, Web of Science, Historical Abstracts; five medical history journals were also searched. Data were collected from City of Ottawa Archives, Archives of the Sisters of Charity of Ottawa, The Ottawa Hospital Libraries, University of Ottawa Libraries, RCPSC and CFPC Archives, Historical Society of Ottawa documents, Ottawa newspaper archives, and professional correspondences. The oral history component consisted of formal interviews with seven practicing and retired Emergency Physicians in Ottawa. Ethics approval was not required though consent was obtained from respondents. Curriculum, Tool, or Material: The literature review yielded the following: PubMed: 218 results, 180 excluded for non-relevance, 3 papers included in analysis. Historical Abstracts: 1 result, overlap with PubMed. Other databases and medical history journals yielded no papers. Along with extensive archival data, these results were used to construct a detailed timeline of EM history in Ottawa and Canada more broadly. Residency training in EM in Ottawa was initiated in 1972 at the impetus of the Board of the Ottawa Civic Hospital. Two main themes recurred in the interviews: resistance from existing specialties to EM becoming a specialty, and early Emergency Rooms staffed by the least trained people treating the least differentiated patients. Early EM physicians were not viewed positively by other specialists. Conclusion: Pioneering EM physicians were forced to validate the specialty as distinct, rigorous, and credible. In Ottawa this was achieved by developing strong core academics and research. Nationally, this has been instrumental in establishing EM as a viable standalone academic specialty. Modern consult pushback may have evolved from existing specialists fighting against the creation of EM combined with their negative perception of EM physicians. These data could be incorporated into learning modules for EM residency academic programs, and the methods applied to other centres.

Introduction: The purpose of this study was to look at outcomes of pediatric patients with early, acute appendicitis who were treated with non-operative management (NOM) with antibiotics. Primary outcomes were subsequent appendectomy or Emergency Department (ED) visits. Methods: The method used for this study was a retrospective chart review of children under the age of 18, looking at outcomes of those who received non-operative management (NOM) for early acute appendicitis between April 2014-April 2015. The inclusion criteria included: (a) Age 0-17, (b) US or CT suggested acute uncomplicated appendicitis (c) Final diagnosis of appendicitis during April 2014-2015. Outcomes that were investigated were repeat ED visits and need for subsequent appendectomy. Results: Data extracted from the EMR found 209 charts with an ED diagnosis of appendicitis. Two charts (.9%) were excluded as they were duplicates. Sixty-seven patients (32%) were excluded after appendicitis was ruled out. One hundred and forty patients (67%) had a final diagnosis of appendicitis, 124 patients (88.6%) were taken directly to the operating room for appendectomy, 16 patients (11.4%) were treated with antibiotics instead of operative management. Three patients who received non-operative management had complex appendicitis, 13 had acute uncomplicated appendicitis. Six patients out of 13 (46%) were successfully treated with antibiotics with no repeat visits to the ED or Pediatric Surgery for appendectomy, 7 patients (54%) required appendectomy after initial treatment with antibiotics. Two patients who underwent appendectomy after initial NOM had no evidence of clinical appendicitis, one patient was taken to the OR based on parent preference and one patient had an episode of abdominal pain that prompted an interval appendectomy four weeks post the episode of abdominal pain. Conclusion: Treatment of acute uncomplicated appendicitis with NOM remains a management option in the pediatric population. Further studies and long term follow up are required to better identify appropriate patients for non-operative management versus operative management.

Introduction: Extended length of stay (LOS) in emergency departments (EDs) and overcrowding are a problems for the Canadian healthcare system, which can lead to the creation of a healthcare access block, a reduced health outcome for acute care patients, and decreased satisfaction with the health care system. The goal of this study is to identify and assess specific factors that predict length of stay in EDs for those patients who fall in the highest LOS category. Methods: A total of 130 patient charts from EDs in Regina were reviewed. Charts included in this study were from the 90th-100th percentile of time-users, who were registered during February 2016, and were admitted to hospital from the ED. Patient demographic data and ED visit data were collected. T-tests and multiple regression analyses were conducted to identify any significant predictors of our outcome variable, LOS. Results: None of the demographic variables showed a significant relationship with LOS (age: p=.36; sex: p=.92, CTAS: p=.48), nor did most of the included ED visit data such as door to doctor time (p=.34) and time for imaging studies (X-ray: p=.56; ultrasound: p=.50; CT p=.45). However, the time between the request for consult until the decision to admit did show a significant relationship with LOS (p<.01).Potential confounding variables analyzed were social work consult requests (p=.14), number of emergency visits on day of registration (p=.62), and hour of registration (00-12 or 12-24-p<.01). After adjustment for time of registration, using hierarchical multiple regression, time from consult request to admit decision maintained a significant predictor (p<.01) of LOS. Conclusion: After adjusting for the influence of confounding factors, “consult request to admit decision” was by far the strongest predictor of LOS of all included variables in our study. The results of this study were limited to some extent by inconsistencies in the documentation of some of the analyzed metrics. Establishing standardized documentation could reduce this issue in future studies of this nature. Future areas of interest include establishing a standard reference for our variables, a further analysis into why consult requests are a major predictor, and how to alleviate this in the future.

Introduction: Development of point-of-care ultrasound (POCUS) image-generating skills requires residents to practice on patients awaiting care in the emergency department (ED) for unrelated reasons. While patients are almost universally agreeable to the scans, there is the possibility that they feel pressured to do so and may have negative experiences that go unreported. The objective of this study was to determine the self-reported patient satisfaction and identify any concerns after educational ultrasounds performed in the ED. Methods: We conducted a survey of patients at a single academic ED. Patients were eligible for enrollment if they had volunteered for an ultrasound when study personnel were available. The survey was administered by a representative from the Patient Affairs Department who advised the patients that the results would remain anonymous and would have no impact on their care. The survey included patient demographics, questions about the consent process, communication by the trainee, adverse reactions and patient satisfaction. The primary outcome was the overall satisfaction level reported by the volunteer patients on a 5-point Likert scale. Secondary outcomes included identification of any discomfort or concerns about the process as expressed by patients. Simple descriptive statistics were used to report survey results. Results: Ninety-nine patients fully completed the questionnaire. Fifty (50%) were women. The age range was 18 to 99 years. Satisfaction among volunteers was high, with 94% of respondents giving a rating of 4 or 5 (five being an excellent experience). No patients gave a negative rating (1 or 2). Three (3%) patients felt “somewhat” pressured to volunteer. A majority of patients (72%) experienced no discomfort during the scan however 16% experienced some physical discomfort. Comments indicated that too much pressure applied with the ultrasound probe or cold ultrasound gel were the main sources of discomfort. Despite some discomfort 95 (95%) patients stated they would likely volunteer again if asked in the future. Conclusion: ED patients volunteering as models for residents learning POCUS expressed generally positive perceptions of their experience. While only a small minority of patients experienced some discomfort or felt pressured into participating, it is important to ensure that patients have a process to communicate any concerns about educational ultrasounds in the ED.

Introduction: Amiodarone may be used for shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), but the effect of prehospital use upon neurological outcomes still unclear. Methods: A prospective province-wide, population based observational study was conducted from January 2006 to March 2016. Adult emergency medical service-treated non-traumatic OHCA patients who received at least one electric defibrillation were included. Amiodarone was administered to patients with VF/ pVT by paramedics based on their clinical assessment, according to provincial guidelines. The outcome of interest was favorable neurological outcomes to hospital discharge, defined as modified Rankin scale of 3 or less. Multivariable logistic regression was performed to compare the proportion of patients with the primary outcome between amiodarone and non-amiodarone groups, further stratified by the number of electrical defibrillation. In addition, to mitigate the potential selection bias, the same logistic regression was conducted in 1:1 propensity score matched groups adjusting for baseline covariates. Results: Of 3,374 overall OHCA patients, 915 (27.1%) were managed with amiodarone. In the amiodarone group, 150 / 915 (16.4 %) patients had a favorable neurological outcome, compared to 455/2,459 (18.5%) in the non-amiodarone group (crude odds ratio [OR] 0.86, 95% CI 0.71 to 1.06). In the multiple logistic regression model, prehospital amiodarone was associated with increased probability of favorable neurological outcomes (adjusted OR 2.11, 95% CI 1.46 to 3.05). With stratification by the number of electrical defibrillation performed, amiodarone treated group showed higher probability of favorable neurological outcomes (1 or 2: adjusted OR 2.71, 95% CI 1.33 to 5.50, 3 and more: adjusted OR 1.67, 95% CI 0.99 to 2.39). Similarly, in 1:1 propensity matched cohort including 882 OHCA patients, the adjusted association persisted (adjusted OR 2.14, 95% CI 1.33 to 3.44). Conclusion: Prehospital administration of amiodarone to non-traumatic OHCA patients was associated with better neurological recovery, especially in those who received fewer electrical defibrillations.

Introduction: Diverting patients away from the emergency department (ED) has been proposed as a solution for reducing ED overcrowding. The objective of this systematic review is to examine the effectiveness of diversion strategies designed to either direct patients seeking care at an ED to an alternative source of care. Methods: Seven electronic databases and grey literature were searched. Randomized/controlled clinical trials and cohort studies assessing the effectiveness of pre-hospital and ED-based diversion interventions with a comparator were eligible for inclusion. Two reviewers independently screened the studies for relevance, inclusion, and risk of bias. Intervention effects are reported as proportions (%) or relative risks (RR) with 95% confidence intervals (CI). Methodological and clinical heterogeneity prohibited pooling of study data. Results: From 7,306 citations, ten studies were included. Seven studies evaluated a pre-hospital diversion strategy and three studies evaluated an ED-based diversion strategy. The impact of diversion on subsequent health services was mixed. One study of paramedic practitioners reported increased ED attendance within 7 days (11.9% vs. 9.5%; p=0.049) but no differences in return visits for similar conditions (75.2% vs. 72.1%; p=0.64). The use of paramedic practitioners was associated with an increased risk of subsequent contact with health care services (RR=1.21, 95% CI 1.06, 1.38), while the use of deferred care was associated with no increase in risk of subsequently seeking physician care (RR=1.09, 95% CI 0.23, 5.26). While two studies reported that diverted patients were at significantly reduced risk for hospitalization, two other studies reported no significant differences between diverted or standard care patients. Conclusion: The evidence regarding the impact of pre-hospital and ED-based diversion on ED utilization and subsequent health care utilization is mixed. Additional high-quality comparative effectiveness studies of diversion strategies are required prior to widespread implementation.

Introduction: Choosing Wisely Canada® (CWC) launched in April 2012. Since then, the Emergency Medicine (EM) top-10 list of tests, treatments and procedures to avoid has been released and initiatives are on-going. This study explored CWC awareness and support among emergency physicians. Methods: A 60-question online survey was distributed to Canadian Association of Emergency Physicians (CAEP) members with valid e-mails. The survey collected information on demographics, awareness/support for CWC as well as physicians’ perceived barriers and facilitators to implementation. Descriptive statistics were performed in SPSS (Version 24). Results: Overall, 324 surveys were completed (response rate: 18%). Respondents were more often male (64%) and practiced at academic/tertiary care hospitals (56%) with mixed patient populations (74%) with annual ED volumes of >50,000 (70%). Respondents were familiar with campaigns to improve care (90%). Among these respondents, 98% were specifically familiar with CWC and 73% felt these campaigns assisted them in providing high-quality care. Respondents felt that the top-5 EM recommendations were supported by high quality evidence, specifically the first 4 recommendations (>90% each). The most frequently reported barriers to implementation were: patients’ expectations/requests (33%), the possibility of missing severe condition(s) (20%), and requirements of ED consultations (12%). Potential facilitators were identified as: strong evidence-base for recommendations (37%), medico-legal protection for clinicians who adhere to guidelines (13%), and support from institutional leadership (11%). Conclusion: CWC is well-known and supported by emergency physicians. Despite the low response rate, exploring the barriers and facilitators identified here could enhance CWC’s uptake in Canadian emergency departments.