Introduction: Diagnosing pulmonary embolism (PE) in the emergency department can be challenging due to non-specific signs and symptoms; this often results in the over-utilization of CT pulmonary angiography (CT-PA). In 2013, the American College of Chest Physicians identified CT-PA as one of the top five avoidable tests. Age-adjusted D-dimer has been shown to decrease CT utilization rates. Recently, clinical-probability adjusted D-dimer has been promoted as an alternative strategy to reduce CT scanning. The aim of this study is to compare the safety and efficacy of the age-adjusted D-dimer rule and the clinical probability-adjusted D-dimer rule in Canadian ED patients tested for PE. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PA, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The age-adjusted D-dimer and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of CT/VQ imaging and the false negative rates were calculated. Results: In total, 1,189 patients were tested for PE. 1,129 patients had a D-dimer test and a Wells score less than 4.0. 364/1,129 (32.3%, 95%CI 29.6-35.0%) would have undergone imaging for PE if the age-adjusted D-dimer rule was used. 1,120 patients had a D-dimer test and a Wells score less than 6.0. 217/1,120 patients (19.4%, 95%CI 17.2-21.2%) would have undergone imaging for PE if the clinical probability-adjusted D-dimer rule was used. The false-negative rate for the age-adjusted D-dimer rule was 0.3% (95%CI 0.1-0.9%). The false-negative rate of the clinical probability-adjusted D-dimer was 1.0% (95%CI 0.5-1.9%). Conclusion: The false-negative rates for both the age-adjusted D-dimer and clinical probability-adjusted D-dimer are low. The clinical probability-adjusted D-dimer results in a 13% absolute reduction in CT scanning compared to age-adjusted D-dimer.

Introduction: Emergency Medicine Physicians have been incorporating Point-of-Care Ultrasound (POCUS) into their practice for over twenty years. Only recently has its use become more widespread in the practice of Pediatric Emergency Medicine (PEM). Recent guidelines have described the scope of applications for PEM physicians. However, no consensus exists as to which applications should be prioritized and routinely taught to PEM fellowship trainees and therefore expected of PEM graduates as they enter practice. The PEM POCUS Network, a multinational group of Physicians with POCUS expertise formed in 2014, set out to reach expert consensus as to which applications should be incorporated into PEM fellowship training curricula. Methods: A multinational group of PEM POCUS experts was recruited from the PEM POCUS Network via a screening process that identified PEM physicians who have performed over 1000 pediatric POCUS scans and met any of one of the following criteria: having 3 years or more experience teaching POCUS to PEM fellows, being local academic POCUS leaders or had completed a dedicated PEM POCUS fellowship. These experts rated each of the 60 possible PEM POCUS applications using a modified Delphi consensus building technique for their importance in inclusion into a PEM Fellowship curriculum. Consensus was reached when >80% of respondents agreed to include or exclude each item. Results: In the first round, 66 out of 92 (72%) PEM POCUS Network members responded to the survey email, of whom 45 met expert criteria and completed the first round. During round 1, consensus was reached to include 18 of the 60 applications in a PEM fellowship curriculum and to exclude 2 applications from a PEM fellowship curriculum. Eighty-two percent (37 /45) of the experts completed Round 2 where 40 items were rated; consensus was reached to include 3 additional applications and exclude 5 applications. The decision was made not to carry on with future rounds after this stage, since no significant changes were observed between the two rounds, with regard to items that had not reached consensus. Conclusion: This project of the PEM POCUS Network reached consensus on 21 applications that should be included in a PEM Fellowship curriculum. This project will have significant impact on how PEM fellowships teach POCUS to their trainees.

Introduction: In its prospective cohorts of independent seniors with minor injuries, the CETIe (Canadian Emergency Team Initiative) has shown that minor injuries trigger a spiral of mobility and functional decline in 18% of those seniors up to 6 months post-injury. Because of their effects on multiple physiological systems, multicomponent mobility interventions with physical exercises are among the best methods to limit frailty and improve mobility & function in seniors. Methods: Pilot clinical trial among 4 groups of seniors, discharged home post-ED consultation for minor injuries. Interventions: 2x 1 hour /week/12 weeks with muscle strengthening, functional and balance exercises under kinesiology supervision either at home (Jintronix tele-rehabilitation platform) or at community-based programs (YWCA, PIED) vs usual ED-discharge (CONTROL). Measures: Functional Status in ADLs (Older American Ressources Scale); Global physical & social functioning (SF-12 questionnaire), physical activity level (RAPA questionnaire) at initial ED visit and at 3 months. Results: 135 seniors were included (Controls: n=50; PIED: n=28; Jintronix: n=27; YWCA: n=18). Mean age was 72.6±6.2 years, 45% were prefrail, 86% and 8% had a fall or motor vehicle-related injuries (e.g. fractures: 30%; contusions: 37%). Intervention could start as early as 7 days post-injury. Seniors in interventions (Home, YWCA or PIED) maintained or improved their functional status (84% vs 60%, p≤0.05), their physical (73% vs 59%, p=0.05) and social (45% vs 23%, p≤0.05) functioning. While 21% of CONTROLs improved their physical activity level three months post-injury, 46% of seniors in intervention did (p≤0.05). Conclusion: Exercises-based interventions can help improve seniors’ function and mobility after a minor injury.

Introduction: Patient satisfaction in the emergency department (ED) has been shown to be associated with patient compliance, likelihood to return, and likelihood to recommend the ED. Understanding the factors that affect patient satisfaction in the ED is important but remains poorly understood. This scoping review consolidates the information from the available literature to offer insight into which key factors influence patient satisfaction. Methods: A literature search using initial criteria identified 683 articles. These titles were subjected to inclusion/exclusion criteria and their relevance was independently reviewed by two authors. Consensus was reached on 24 articles to be included, and these were then classified according to study design (class I=observational studies, class II=focus group/qualitative studies, class III=reviews), as well as multiple other factors (ED type, volume of patients, sample size, population, type of study, methodology, study measures, statistical analysis, reliability and conclusions). Using these factors, 25 different ED care attributes were examined in the primary literature, and then narrowed to the 6 most commonly studied factors with 3 categories (wait times, communication/information received in the ED, and interpersonal skills of staff). Results: The impact of wait times (WT) on patient satisfaction in the ED was addressed in 58% of the articles and various studies have found that longer perceived WTs (the length of WTs as reported by patients) are associated with poorer patient satisfaction. Information delivery demonstrated statistically significant associations to both patient satisfaction and the likelihood of a positive recommendation. Interpersonal skills of the staff also demonstrated a strong association with patient satisfaction. Conclusion: The most common factors affecting patient satisfaction in the ED can be categorized under wait times, communication, and the interpersonal skills of the staff. However, the literature in this area is weak, and well-designed comparative studies of the relative importance of each of these factors are necessary to support evidence-based policy making and ultimately improve patient satisfaction.

Introduction: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the Emergency Department (ED) associated with significant mortality and morbidity. Recent evidence suggests that overt-transfusion is associated with poor patient outcomes and that stable patients above a hemoglobin (hgb) above 70 g/L should be transfused judiciously. This retrospective health records review aims to determine the proportion of NVUGIB patients with hemoglobin greater than 70 g/L who were still appropriately transfused based on clinical parameters. Methods: A retrospective review was conducted on randomly selected patients that presented to one of two major tertiary hospitals with a primary diagnosis of NVUGIB who received blood products, despite a presenting hemoglobin >70 g/L. Standardized case report forms were developed through chart abstraction using a pilot-tested template. The appropriateness of transfusion was then adjudicated separately by a trained medical student and an emergency physician; discrepancies were resolved by discussion. Results: Following independent review of the charts, agreement was met on 94% (45/48) of the charts and after collective discussion 100% consensus was reached and all 48 patients’ transfusion appropriateness and categorized into one of three groups: Appropriate, Potentially avoidable, and clearly avoidable. Only in 22.9% (11/48) of the cases was transfusion deemed to be clearly avoidable while emergency physicians appropriately transfused 45.8% (22/48) of patients based on clinical status and other factors. In 31.3% (15/48) of the cases, transfusion was potentially avoidable in favor of other management options. We calculated the mean GBS for the appropriate, potentially avoidable, and clearly avoidable categories yielding 12.8, 12.7, and 10.2 respectively. Mortality occurred in 2 of the 48 cases (4%). Conclusion: In most instances, emergency physicians are effectively integrating hemoglobin thresholds and clinical status to determine if a patients with NVUGIB and hgb >70 require blood products.

Introduction: In the context of a shrinking healthcare budget, poor physician cost awareness, and continued over-utilization of low-value tests in the emergency department, we re-designed our computerized order entry system to reduce the use of coagulation testing. Methods: A hospital-based prospective pre-post analysis following de-bundling of INRPTT testing in two academic hospital emergency departments (annual visits 140,000). All participants aged 18 years or older undergoing evaluation and/or treatment at either of during the period of August 1, 2015 to July 24, 2016 were included. Primary outcome is coagulation testing utilization rates and associated costs. Results: Unbundling INR and aPTT testing resulted in significantly decreased bundled INRPTT testing relative to baseline (INRPTT tests per patient per day: 0.60 [95% CI: 0.57-0.62] vs. 0.98 [95% CI: 0.98-0.99], p=0.000), with significantly increased targeted testing (INR tests per patient per day: 0.39 [95% CI: 0.37-0.42] vs. 0.00 [95% CI: 0.00-0.01], p=0.000; PTT tests per patient per day: 0.33 [95% CI: 0.30-0.36] vs. 0.01 [95% CI: 0.00-0.01], p=0.000). As a result of unbundling, there was a significant decrease in costs associated with coagulation testing relative to baseline (Cost per day: $958.52 [INRPTT $592.78+INR $183.91+PTT $181.83] vs. $1,074.50 [INRPTT $1,069.76+INR $2.06+PTT $2.68], p=0.000), realizing estimated daily and yearly savings of $115.98 and $42,332.70, respectively. Conclusion: Compared to baseline practice patterns, unbundling coagulation testing resulted in the reduction of coagulation testing suggesting system design and user workflows to be an integral factor to provider practice patterns. Given the significant cost-savings, we recommend institutions carefully re-evaluate their system design and user workflows to optimize emergency department laboratory utilization.

Introduction: Emergency department (ED) visits for mental health and addiction related complaints are common and appear to be increasing. It is believed these patients come to the ED requiring urgent assessment either because they do not have a primary care or psychiatric healthcare provider or access to their provider is not available in a timely fashion. The objective of this study was to describe healthcare utilization in the previous 12 months by patients presenting to the ED with a mental health complaint. Methods: Between April-November 2016, a convenience sample of adult (≥18 years) patients presenting to an academic ED (annual census 65,000) with a mental health and/or addictions complaint were invited to complete a paper-based survey to determine their usage of ten different mental healthcare resources over the previous 12 months. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 134 patients who completed the survey, mean (SD) age was 37.9 (15.7) years and 64 (47.8%) were male. Only 7 (5.2%) patients did not access any mental health resource in the previous 12 months, and the most commonly accessed resource was hospital EDs (102, 76.1%), with 24 (23.5%) of these patients using the ED at least 6 times. Patients also accessed a variety of other mental health resources, with 28 (20.9%) seeing their family physician, 20 (14.9%) seeing their psychiatrist/psychologist, and 61 (45.5%) seeing both in the previous 12 months. Only 6 (5.9%) patients used the ED exclusively for a mental health related complaint. By comparison, respondents accessed other specific mental health resources such as crisis centres (19, 14.2%), helplines (34, 25.4%), and peer-support groups (24, 17.9%) less often. Conclusion: These findings suggest that the ED is the most commonly used mental health resource for this population. However, these patients also frequently access family physicians and psychiatrists/psychologists, with community resources such as crisis centres, helplines, and peer-support being used less often. This suggests that lack of timely access to other mental health resources may be the primary motivation for accessing the ED.

Introduction: The 2007 SAEM Knowledge Translation consensus conference proposed areas of research in evidence-based clinical algorithms (EBCAs) using clinical decision rules (CDRs) and practice guidelines (CPGs). This project sought to explore the evidence awareness and utilization of various clinical decision rules (CDRs) in emergency medicine (EM) practice. This project sought to explore the evidence awareness and utilization of various clinical decision rules (CDRs) in emergency medicine (EM) practice. Methods: An international survey was administered via international EM organizations using modified Dillman methods. Categories of CDRs included imaging (7), infections (3), neurology (2), venous thromboembolism (VTE; 2), and other (2). Evidence levels were queried using JAMA User’s Guide CDR rating scales (Levels I-IV). Confidence with supporting evidence and utilization of CDRs in practice were assessed on 7-point Likert scales. Correlation of evidence understanding and practice utilization were calculated using Spearman rho methods. Results: The majority of respondents (n=378) were Canadian (72%), <15 years full practice (64%), residency trained (90%), and trained in CDR methods (73%). Evidence ratings were deemed high for all CDRs, although confidence in evidence ratings and practice utilization were more variable for specific rules. Comfort with evidence ranking and utilization in clinical practice were highly correlated (ρ<0.0002). Conclusion: Among Canadian residency CDR trained physicians, evidence ranking is strongly correlated with use in self-reported clinical practice. There is insufficient data from non-Canadian respondents to draw firm correlations. Their remains opportunity to fully disseminate high quality CDRs and encourage incorporation into EBCA practice.

Introduction: There is strong evidence that socio-economic factors such as income, housing and ethnicity are linked to health outcome disparities for emergency department (ED) patients. However, lack of real-time patient data has limited our ability to identify, understand and address health disparities. During a 14-week period, we assessed the feasibility and acceptability of the systematic collection of patient-level equity data in a busy tertiary care urban ED. Methods: We assessed feasibility by directly observing impact on registration time, percentage of patients on which data was collected, and ambulance patient data collection. We also assessed acceptability to patients, registration staff and clinicians through structured interviews of patients systematically sampled, focus group and surveys of registration staff and survey of clinicians. Results: Over the course of the study, equity data was collected on 2017 patients. Capture rate peaked in week 7 with 51% of eligible patients offered the equity questions and 30% answering. Average patient registration time increased from 215 seconds to 345 seconds (60%). Data collection with ambulance patients did not appear feasible. Patients (n=30) reported being comfortable with most questions except income (47% comfortable). 93% believed it could improve health services. However, a small number of patients voiced concern that the data could result in discrimination. Registration staff required sustained support and engagement, but some continued to feel uncomfortable with offering the questionnaire to some patients. Conclusion: Large scale collection of equity data is feasible but requires additional resources and sustained staff and patient support. Patient participation rate is likely to remain relatively low and is likely to underestimate disadvantaged groups. Data collection at multiple points within an institution may improve capture rate.

Introduction: Excessive consumption of alcohol is associated with harm and responsible for up to 30% of emergency department (ED) visits. ED visits and length of stay (LOS) related to alcohol intoxication have increased over the last decade. The objective of this study was to compare the ED LOS of alcohol intoxicated and non-alcohol intoxicated patients presenting to the ED with acute head injury. Methods: This was a nested cohort analysis of patients screened for enrollment in a randomized controlled trial assessing minor traumatic brain injury (MTBI) discharge instructions in the ED of an academic tertiary care hospital (annual census 65,000). Patients aged 18 to 64 years presenting to the ED with a Canadian Emergency Department Information System (CEDIS) chief complaint of a head injury or suspected concussion occurring within 24 hours were eligible for study inclusion. Patients were identified as acutely intoxicated by their treating clinical providers. ED LOS for patients acutely intoxicated and those not intoxicated was compared using a Mann-Whitney U test using the Hodges-Lehmann method. Proportional differences were assessed using chi-square statistics. Results: A total of 164 patients were included in the analysis, 46 (28.0%) intoxicated and 118 (72.0%) not intoxicated. Median (IQR) ED LOS was 2.9 (1.5, 6.6) hours for intoxicated and 1.8 (1.3, 2.9) hours for non-intoxicated patients (Δ1.1 hours; 95% CI: 0.4, 1.8). Arrival by ambulance was higher in the intoxicated (73.9%) compared to the non-intoxicated (29.7%) group (Δ44.3%; 95% CI: 27.6, 57.1). Patients were more likely to have experienced assault in the intoxicated (34.8%) compared to the non-intoxicated (6.8%) group (Δ28.0%; 95% CI: 14.5, 42.8). There no difference in the proportion of patients who arrived after daytime hours, had a brain computed tomography, received analgesia in the ED, had another traumatic injury or had a history of psychiatric illness. Conclusion: One third of patients screened for a randomized controlled trial for MTBI were deemed ineligible for study inclusion due to acute alcohol intoxication. Alcohol intoxication was associated with prolonged ED LOS. Future studies specifically aimed at identifying factors that impact care on this frequent ED patient population are needed.

Introduction: Social desirability bias is a systematic error in self-report measures resulting from the desire of respondents to avoid embarrassment and project a favourable image of themselves to others. This bias may decrease the accuracy of self-reported health outcomes collected in health research compromise the validity of research findings. This study compared outcomes obtained by patient self-report vs. the same outcomes after undergoing verification and external adjudication, in trial involving patients with acute asthma. Methods: Cross-sectional analysis of outcome data obtained in a randomized controlled trial conducted in 6 Canadian emergency departments (ED). Adult patients were allocated to receive usual care (UC), opinion leader [OL] guidance to their primary care provider (PCP), or OL guidance+nurse case-management [OL+CM] for patients (NCT01079000). Asthma relapses and PCP follow-up visits were blindly assessed through patient self-report 30 and 90 days after their ED presentation for acute asthma. Each reported event was verified through the provincial electronic medical record, the ED Information Systems, and by calling the PCPs’ offices. Two study investigators, blinded to the study interventions, independently reviewed and adjudicated the verified outcomes. Disagreements were resolved by consensus prior to un-blinding. Results: Overall, 367 patients were enrolled; more were female (64%) and the median age was 28 years. Overall, patient follow-up was obtained in 85% of cases. The proportion of asthma relapses occurring within the first 90 days were lower when considering patient self-report than when considering the adjudicated outcomes (17%[39/227] vs. 19%[70/367]). The proportion of PCP follow-up visits occurring within the first 30 days were higher when considering patient self-report than when considering the adjudicated outcomes (47%[139/290] vs. 40%[146/367]). The pattern was similar, regardless of the arm of the study (UC vs. OL vs. OL+CM arms); outcome disagreement did not influence the direction of magnitude of the treatment effect. Conclusion: Social desirability bias could have influenced the outcomes obtained by patient self-report in this ED-based study. The direction of the bias was the same for both outcomes; however, the variation did not change the study results. This bias may play a role in studies with smaller sample sizes.

Introduction: Domestic violence (DV) rates in smaller cities have been reported to be some of the highest in Canada. It is highly likely that emergency department staff will come across victims of intimate partner violence (IPV) in their daily practice. Elsewhere we have found low rates of IPV documentation as well as underutilization of current tools in the ED. The purpose of this study is to describe ED staff awareness and knowledge surrounding IPV, currently accepted screening questions, and available screening tools. Methods: To assess awareness and knowledge, a cross-sectional online survey was distributed to ED staff (LPNs, NPs, Physicians, Residents, RNs) via staff email lists three times between July and October 2016, with a response rate of 45.9% (n=55). The primary outcomes were correct identification of appropriate IPV questions. Secondary outcomes included awareness of screening tools (HITS, WAST, PVS, AAS), whose role it is to question patients, and whether or not formal training has been received. Results: When asked to identify recommended questions for asking about IPV, staff were more likely to choose screening questions (75.3%; 95% CI 69.3% to 80.6%) compared to questions that are not recommended (23.8%; 95% CI 19.4% to 30.7%). However, 87.3% of respondents were not aware of current screening tools. 49.1% believed that all patients with typical injuries (ex. facial injury), should have further questioning about IPV, 20% believed that all patients with any injury, and 16.4% believed that all patients should be questioned about IPV. 89.1% also felt that it is both the physician and nurse’s role to question patients about IPV. Finally, 81.8% of ED staff did not receive any formal training on domestic or intimate partner violence. Conclusion: The present study indicates that there may be a gap in education surrounding this high risk condition as seen by the lack of knowledge surrounding current tools, lack of consensus on who should be questioned, and lack of training. Therefore, introduction of a knowledge translation piece may be beneficial to both ED physicians and nurses.

Introduction: Domestic violence (DV) rates in smaller cities have been reported to be some of the highest in Canada. It is highly likely that emergency department staff will come across victims of intimate partner violence (IPV) in their daily practice. However, elsewhere we have found a lack of knowledge of current tools as well as lack of training in ED staff. Furthermore, these findings may also be reflected by low rates of IPV documentation, especially in high-risk cases. The purpose of the current study is to determine if ED staff would be willing to implement a brief IPV screening tool, the Partner Violence Screen (PVS) in their daily practice. It consists of the 3 questions: Have you ever been hit, kicked, punched or otherwise hurt by someone within the past year, and if so, by whom? Do you feel safe in your current relationship? Is there a partner from a previous relationship that is making you feel unsafe now? Methods: A cross-sectional online survey was distributed to ED staff (LPNs, NPs, Physicians, Residents, RNs) via staff email lists three times between July and October 2016, with a response rate of 45.9% (n=55). The survey included a 5-question Likert scale. The primary outcome was whether ED staff are willing to implement a new case-finding tool in their daily practice. The secondary outcome was to assess whether staff would find this tool beneficial in case-finding for IPV. Results: 43.6% of staff responded that they are likely to use the tool routinely, 29.1% were unsure, and 2.7% very likely. 7.27% and 3.64% stated their predicted use as unlikely and very unlikely, respectively. In addition, 43.6% of staff thought that the PVS would be beneficial in case finding for IPV, 40% were unsure, 12.7% thought very likely, 1.82% unlikely, and 1.82% very unlikely. Conclusion: These findings suggest that emergency department staff may be receptive to and find the introduction of the PVS beneficial in identifying cases of IPV. Future directions will include the introduction of this tool through a knowledge translation education piece in order improve the identification process for and awareness of a high-risk condition in a vulnerable population group.

Introduction: To help mitigated risks associated with red blood cell transfusions, CWC guidelines recommend practicing restrictively. Transfusion Medicine recommends using a Hgb threshold of 70 g/L, and ordering a single unit at a time (with reassessment after). The purpose of this study is to investigate Emergency Department (ED) compliance with these more restrictive thresholds among hemodynamically stable patients. Methods: A retrospective analysis was performed on data from all emergency visits to 4 adult urban ED sites from July 1 2014 to July 1 2016. We excluded unstable patients (CTAS1, temperature >38°C, HR >100 bpm, RR >20 rpm, systolic BP <90 mmHg, and O2 sat <85%) and certain others (patients without a Hgb level, patients who left without being seen, and orders cancelled via patient discharge). After applying exclusion factors, we examined transfusions ordered. Appropriateness was assessed using the stratified Choosing Wisely Canada Guidelines for Transfusion. As an adjunct, IV iron therapy data was also analyzed for the same period between July 1 2014 and July 1 2016, excluding patients who did not have a Hgb level. Results: We identified 1329 eligible patients (54% female), with a mean age of 68 and average first hemoglobin of 72 g/L. Across all groups, 16% of patients received only 1 unit of blood. 19% of transfused patients had a hemoglobin less than 60 g/L, 45% had a Hgb <70 g/L, 32% had a Hgb 70-80 g/L, 14% had a Hgb 81-90 g/L, and 8% had a Hgb >90 g/L. Over the same two-year period, 178 patients received IV iron. The average Hgb for those patients was 82 g/L. Conclusion: A retrospective analysis documents a significant likelihood of pRBC over-transfusion among Emergency Department physicians and an underutilization of IV iron therapy for certain hemodynamically stable and anemic patients. The development of audit and feedback methods, and creation of a clinical pathway may help address the rate of over-transfusion.

Introduction: The Collaborative Emergency Centre (CEC) model of health care delivery was implemented in rural Nova Scotia in July 2011 without an identifiable, directly comparable precedent. It features interprofessional teams working under one roof with the goal of providing improved access to timely primary health care, and appropriate access to 24/7 emergency care. One important component of the CEC model is overnight staffing by a paramedic/registered nurse team consulting with an offsite physician via telephone. Our objective was to ascertain the attitudes, feelings and experiences of paramedics working within the CEC construct. Methods: We conducted a qualitative study, guided by the principles of grounded theory. Semi-structured telephone interviews were carried out by the principal investigator with paramedics with experience working in a CEC in the province of Nova Scotia. Interviews were recorded, transcribed and analyzed. Analysis involved an inductive and deductive grounded approach using constant comparative analysis. Data collection and analysis continued until thematic saturation was reached. Results: Fourteen paramedics participated in the study. The majority were male (n=10, 71%), with a mean age of 44 years (STD=8.8) and mean experience as a paramedic of 14 years (STD=9.7). Four major themes were identified from the data: 1) leadership support, encompassing support from Emergency Health Services and Government prior to and after implementation of the model, 2) team work and collaboration, including interprofessional relationships among members of the healthcare team, 3) value to patients and the communities, and 4) professional and personal benefits of working in CECs. Conclusion: Paramedics have found working in CECs to be both professionally and personally rewarding. They perceive the CEC model to be of great value to the patients and communities it serves. Key lessons that might help future expansion of the model in Nova Scotia and other jurisdictions across the country include the importance of building and strengthening relationships between paramedics and nurses, and the need for greater feedback and support from leadership.

Introduction: Resuscitation is a dynamic, complex and time-sensitive field which encompasses management of both critically-ill patients as well as large multidisciplinary teams. Expertise in this area has not been adequately defined, and to date, no research has directly examined the decision-making and cognitive processes involved. The evolving paradigm of competency-based medical education (CBME) makes better defining expertise in this field of critical importance to aid in the development of both educational and assessment methods. The technique of cognitive task analysis (CTA) has been used in a variety of fields to explicate the cognitive underpinnings of experts. Experts, however, often have limited insight and incomplete recall of their decision-making processes. We hypothesized that the use of eye-tracking, which provides the combination of first-person video as well as an overlying gaze indicator, could be used to enhance CTA to better understand the defining characteristics of experts in resuscitation. Methods: Over an 18-month period a sample of 11 traumatic resuscitations were obtained, each led by one of four pre-selected expert physicians outfitted with the Tobii Pro Eye-Tracking Glasses. After each resuscitation, the participant was debriefed using a cued-recall, think-aloud protocol while watching his or her corresponding eye-tracking video. A subsequent qualitative analysis of the resulting video and debrief transcript was performed using an ethnographic approach to establish emerging themes and behaviours of the expert physicians. Results: The expert participants demonstrated specific, common patterns in their cognitive processes. In particular, participants exhibited similar anticipatory and visual behaviours, dynamic communication strategies and the ability to distinguish between task-relevant and task-redundant information. All participants reported that this technique uncovered otherwise subconscious aspects of their cognition. Conclusion: The novel combination of eye-tracking technology to supplement the CTA of expert resuscitationists enriched our understanding of expertise in this field and yielded specific findings that can be applied to better develop and assess resuscitation skills.

Introduction: The Calgary Stampede is a two-week mass gathering occurring annually in July. Clinicians have anecdotally noted increases in emergency department (ED) and urgent care (UC) visits, especially for complaints related to substance misuse and violence. Our objectives were: 1) to determine if there is an increase in overall visits to EDs and UCs during the Stampede, and 2) to determine if there are increases in presentations related to trauma, violence, or intoxication. Methods: This observational study used prospectively collected administrative data from five EDs and two UCs in Calgary. For the years 2013 to 2016, daily average data during Stampede dates were compared to the data from the 21 days immediately preceding and following the event. Dates were selected to incorporate a similar proportion of weekends and weekdays in the Stampede and non-Stampede periods. The primary outcome was daily average ED and UC utilization. Secondary outcomes included time of arrival, utilization by demographic groups, complaint category at triage, or International Statistical Classification of Diseases, 10th revision (ICD-10) diagnosis. Results: The study period included 263 380 individual ED and UC visits (34 492 Stampede and 228 888 non-Stampede visits). Daily average ED and UC visits increased by 2.1% (p<0.0001) during the Stampede period. Increases in utilization were identified in specific subgroups: male, ambulance arrival, and nighttime arrival between 2000 and 0400 (all p<0.05). The Stampede period saw a marked increase in CTAS 1 visits (16.2%, p<0.01), triage complaints of lacerations (12.4%, p<0.0001) and blunt trauma (19.4%, p<0.0001), and the ICD-10 diagnosis of substance misuse (23.9%, p=0.01). Visits triaged to the minor treatment areas increased by 9.5% (p<0.0001), again most markedly at night (15.3%, p<0.0001).No differences were detected for triage complaints of altered level of consciousness, sexual assault, head or neck injury, limb injury, or social problems. Conclusion: The Calgary Stampede provokes appreciable changes in overall ED and UC utilization, with marked increases in nighttime visits, visits by men, trauma or substance abuse-related complaints, and minor treatment visits. This data may be useful in manpower planning to ensure optimal patient flow and service delivery during mass gatherings.

Introduction/Innovation Concept: Introduction of a new simulation program including structured debriefing represents a substantial challenge. Debriefing performance is critical for facilitating learning in simulation. However, many faculty members are unfamiliar with the debriefing process. Faculty receives no training for conducting impactful and safe debriefs. Consequently, they are uncomfortable and often disengaged. We designed, implemented, and evaluated an innovative faculty-debriefing curriculum. Do professional development efforts in simulation debriefing teaching result in improved engagement in simulation teaching by faculty, increased comfort with simulation teaching, and an acceptance of a critical thinking framework for simulation teaching? Methods: We designed the curriculum to include the flipped classroom and deliberate practice models. Participants (n=26; 42% of Emergency Medicine Faculty) were pre-circulated course materials, and then attended a full day course to introduce the simulation setting, the equipment, and two practice scenarios. Each scenario was followed by a group debrief. Twenty-one participants (80.7% response rate) completed pre and post course surveys; we analyzed the data using descriptive statistics. Curriculum, Tool, or Material: Results: Descriptive findings from a pre-course and post-course survey were conducted. Prior to participating in the innovation, 75% had participated in simulation teaching at Western, but only 30% of this faculty being comfortable with this teaching format. 65% of participants had no formal simulation training and 95% had no training in debriefing. Results of the post-course survey revealed 100% satisfaction with the flipped classroom model; and 48% and 52% were extremely likely and very likely to attend future faculty development courses respectively. 100% of participants felt comfortable in participating in debriefing post simulation teaching with 50% feeling comfortable to do this independently without a co-debriefer. 100% of participants felt that the critical thinking framework that was presented in the course for a debriefing model would translate into their clinical teaching in the future. Conclusion: Faculty development has a critical role to play in promoting academic excellence and innovation. Faculty development programs must respond to the changes in medical education. This education project integrated a unique model of learning for faculty, engaged faculty, and increased their comfort level for teaching in simulated setting and utilizing structured debriefing.

Introduction: Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation. Methods: We conducted a one-year health records review of patients ≥18 years presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Trained research personnel collected data on patient characteristics and determined if patients had an unplanned recurrent ED visit for hyperglycemia within 30 days of their initial presentation. Multivariate logistic regression models using generalized estimating equations to account for patients with multiple visits determined predictor variables independently associated with recurrent ED visits for hyperglycemia within 30 days. Results: There were 833 ED visits for hyperglycemia in the one-year period. 54.6% were male and mean (SD) age was 48.8 (19.5). Of all visitors, 156 (18.7%) had a recurrent ED visit for hyperglycemia within 30 days. Factors independently associated with recurrent hyperglycemia visits included a previous hyperglycemia visit in the past month (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.1-5.8), age <25 years (OR 2.6, 95% CI 1.5-4.7), glucose >20 mmol/L (OR 2.2, 95% CI 1.3-3.7), having a family physician (OR 2.2, 95% CI 1.0-4.6), and being on insulin (OR 1.9, 95% CI 1.1-3.1). Having a systolic blood pressure between 90-150 mmHg (OR 0.53, 95% CI 0.30-0.93) and heart rate >110 bpm (OR 0.41, 95% CI 0.23-0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit. Conclusion: This unique ED-based study reports five risk factors and two protective factors associated with recurrent ED visits for hyperglycemia within 30 days in patients with diabetes. These risk factors should be considered by clinicians when making management, prognostic, and disposition decisions for diabetic patients who present with hyperglycemia.

Introduction: Intubation is a high-risk procedure that is frequently performed within the ED. Few Canadian centres have a system in place to monitor intubation frequency, indications, methods used, operator characteristics, first-pass success, and adverse event rates. There are no published data on the frequency of success or complications of emergency airway management in Canada. An airway registry would be a valuable quality improvement (QI) tool for assessing the impact of practice changes such as pre-intubation checklists and for identifying patients with “difficult airways.” We describe the development and implementation of an airway registry in a Canadian tertiary-care centre. Methods: We created a collaborative working group with staff from EM, ICU, Respiratory Therapy (RT), and Privacy. An airway data form was created. Over a 3 month trial period, the form was completed by RTs following each non-OR intubation. At our centre, RTs are present at every intubation outside of the OR. If a patient was intubated outside of the hospital, forms were completed using verbal handover. RTs also provided constructive feedback and after 3 months the form was revised and finalized. Medical student volunteers entered data from the forms and from chart reviews into a secure online database created for this purpose. Results: We have enrolled 373 patients over the first 5 months with ongoing enrolment at the time of abstract submission. The airway form captures the seniority and discipline of the intubator, preparation, technique, and any airway manoeuvres that were used. The form also captures Cormack-Lehane airway grading, confirmation techniques, complications, and the option to identify the patient as a “Difficult Airway.” Privacy permission was granted to include patient identifiers in the airway registry so that additional information from chart reviews could be obtained at a later date. Preliminary results will be presented at the conference. Conclusion: Our airway registry tracks intubation performance and may identify factors associated with adverse patient outcomes, which could prompt system-wide changes. Comparison of intubation performance to other Canadian institutions may be possible if similar airway registries are implemented. The development and implementation of an airway registry requires multi-disciplinary collaboration, engagement, and user feedback.