Introduction: Approximately 30,000 hip fractures occur annually in Canada, and the incidence will increase with an aging population. Pain control remains a challenge with these patients, as many are elderly and prone to delirium. Regional anesthesia has shown to be very effective with minimal risks, but it is not clear how often emergency physicians are using this technique to provide analgesia for patients with proximal hip fractures. This is the first Canada-wide survey to evaluate the use of regional anaesthesia in the emergency department for hip fractures. It also evaluates physician comfort level with performing these blocks, perceived educational needs in this area, and barriers to performing nerve blocks. Methods: A 13-question survey was sent to 1041 members of the Canadian Association of Emergency Physicians via email in January and February of 2016. Data was collected and analysed using an online collection program called “Survey Monkey”. Ethics approval was obtained through the University of Manitoba Research Ethics Board. Results: 272 Emergency physicians and residents took part in the survey. The majority of respondents (75.9%) choose intravenous opioids as their first line of analgesia and only 7.6% use peripheral nerve blocks (PNB) as their first line choice for analgesia in hip fracture. In response to practitioner comfort with PNBs for hip fractures, most were not at all confident (45.0%) in their ability and many respondents have never performed a nerve block for a hip fracture (53.9%). The most commonly identified barriers to performing PNBs include lack of training, the time to perform the procedure and a lack of confidence. A larger percentage of respondents (34.2%), identified having had no training and no knowledge of how to perform PNBs for hip fractures. Conclusion: The vast majority of Canadian emergency physicians who took part in this survey do not utilize PNBs as a method of pain management for hip fractures. Over half have never performed one of these procedures and many have never received training in how to do so. Future efforts should focus on improving access to education, disseminating information regarding the effectiveness of PNB, and addressing logistical barriers in the ED.

Introduction/Innovation Concept: In the controlled chaos of the emergency department (ED) it can be difficult for medical trainees similarly recognize that there is definite order to the chaos, and many may never truly appreciate its complexity. How should medical learners develop this skill? Didactic teaching cannot effectively portray the complexities of managing the ED. Much like education in cardiac arrest, trauma, and multi-casualty incident management, it is our belief that the management of patient flow through the ED is best learned through simulation. Thus, we developed GridlockED, a board game that requires players to work cooperatively to manage a simulated ED to win the game. Methods: GridlockED development took place over a six-month period during which iterative cycles of gameplay and redevelopment were used to optimize game mechanics and improve player engagement. The patient cases were created by medical students (PS, DT, JR) and subsequently reviewed for content validity by two attending emergency physicians (TC, AP). Input from attending emergency physicians, residents, medical students, and laypeople was integrated into the game through a Plan-Do-Study-Act (PDSA) model. Curriculum, Tool, or Material: Our game includes: 1) The game board; 2) Patient cards, which describe a patient, their level of acuity, and the tasks that must be completed in order to disposition the patient; 3) Event cards, which cause random positive or negative events to occur-much like random events occur in real life that change the dynamics of the ED; 4) Game Characters, which move around the board to denote where tasks are being completed; 5) A tracking sheet to follow how many tasks each character has performed in each turn; 6) A shift-time clock, which is used to track the ‘hours’ of your shift; 7) A ‘Gridlock counter’, which tracks how many ED backups or adverse patient outcomes occur (‘Gridlocks’). The goal of the game is to work cooperatively with your teammates to complete patient tasks and move patients through the ED to an ultimate disposition (e.g. admission, discharge). The game is won if you finish your shift before reaching the maximum number of ‘Gridlocks’ allowed. Conclusion: Initial responses to GridlockED have been very positive, supporting it as both an engaging board game and potential teaching tool. We are excited to see it validated through research trials and possibly incorporated into emergency medicine training at both student and postgraduate training levels.

Introduction/Innovation Concept: Digital media are a new frontier in medical education scholarship. Asynchronous education resources facilitate a multi-modal approach to teaching, and allows residents to personalize their learning to achieve mastery in their own time. The CanadiEM Digital Scholars Program is a nationwide initiative that provides residents with practical experiences in creating digital educational materials under the supervision of experts in the field. The program allows for collaboration and access to mentorship from top digital educators from across North America. Methods: Interested residents accepted into the program spent a period of their PGY4 year completing modules developed in the theory and science behind digital education. Four modules, developed in an iterative process, have been built on the topics of podcasting, blogging, digital identity, and patient communication. Each fellow was supervised members of the CanadiEM team, a faculty member from the resident’s home institution, and digital experts from across North America. Curriculum, Tool, or Material: The first fellow completed all aspects of the designed curriculum. Above this, he also engaged in blog content creation, initiated research on digital scholarship, and managed the editorial section of CanadiEM. The second fellow is currently halfway through his year (and is expected to complete the program within the year) and has co-authored 30 blog posts and 53 podcasts in 6 months. Conclusion: The CanadiEM Digital Scholars Program utilizes a novel approach to foster development of digital educators utilizing experts across North America. We have demonstrated the feasibility and sustainability with our initial pilot years. This program is being scaled next year to include two scholars per year, which will facilitate cross-collaboration between the scholars.

Introduction/Innovation Concept: Demand for training in global health emergency medicine (EM) practice and education across Canada is high and increasing. For faculty with advanced global health EM training, EM departments have not traditionally recognized global health as an academic niche warranting support. To address these unmet needs, expert faculty at the University of Toronto (UT) established the Global Health Emergency Medicine (GHEM) organization to provide both quality training opportunities for residents and an academic home for faculty in the field of global health EM. Methods: Six faculty with training and experience in global health EM founded GHEM in 2010 at a UT teaching hospital, supported by the leadership of the ED chief and head of the Divisions of EM. This initial critical mass of faculty formed a governing body, seed funding was granted from the affiliated hospital practice plan and a five-year strategic academic plan was developed. Curriculum, Tool, or Material: GHEM has flourished at UT with growing membership and increasing academic outputs. Five governing members and 9 general faculty members currently run 18 projects engaging over 60 faculty and residents. Formal partnerships have been developed with institutions in Ethiopia, Congo and Malawi, supported by five granting agencies. Fifteen publications have been authored to date with multiple additional manuscripts currently in review. Nineteen FRCP and CCFP-EM residents have been mentored in global health clinical practice, research and education. Finally, GHEM’s activities have become a leading recruitment tool for both EM postgraduate training programs and the EM department. Conclusion: GHEM is the first academic EM organization in Canada to meet the ever-growing demand for quality global health EM training and to harness and support existing expertise among faculty. The productivity from this collaborative framework has established global health EM at UT as a relevant and sustainable academic career. GHEM serves as a model for other faculty and institutions looking to move global health EM practice from the realm of ‘hobby’ to recognized academic endeavor, with proven academic benefits conferring to faculty, trainees and the institution.

Introduction: In 2008 British Columbia created a nurse (RN) staffed telephone triage service, (TTS) to provide timely advice to non-911 callers (811). A perception exists that some callers are inappropriately directed to emergency departments (EDs) thereby worsening crowding. We sought to determine whether supplementary emergency physician (EP) triage would decrease ED visits while preserving caller safety and satisfaction. Methods: TTS RNs use computer algorithms and judgment to triage callers. Potentially sick callers are directed to “seek care now” (red calls). Often this is to an ED depending on acuity and time of day. In the Vancouver Health Region from April-September 2016 between 8:00-24:00 hours, a co-located EP also spoke with “red” callers to provide further guidance. Callers were followed up with 1 week and satisfaction was evaluated on a 5-point Likert scale. The TTS data was linked to the regional ED database to assess ED attendance within 7 days, and the provincial vital statistics database for 30-day mortality. Our primary outcome was the proportion of unique “red” callers who did not attend the ED compared with a historical cohort one year earlier without EP triage in place. Secondary outcomes were the proportion of “red” callers advised not to attend the ED but (a) attended, (b) admitted, or (c) died. Results: In the study period there were 5105 “red” calls of which 3440 were transferred to the EP (67.4%), 2958 of EP assessed callers (86.0%) had a family doctor, but only one-quarter of such patients could contact their family doctor. Overall, 2301/3440 “red” callers did not attend an ED (67.0%) compared to 2508/4770 in the control period (52.6%), for an absolute reduction of 14.4% (95% CI 12.2 to 16.4%, p<0.0001). In callers for those <17 years old there was a 20.3% (95% CI 16.5 to 24.1%) reduction in ED visits compared to the control group: 771/1520 (50.7%) vs 364/1067 (30.4%). 40% of callers attending an ED (458/1139) were advised to try non-ED follow up by the MD and 108 (9.5%) were admitted, with no difference in 30-day mortality between groups. Age and CTAS distribution were similar between the two groups and the non MD-transferred cohort. Mean caller satisfaction was excellent (4.7/5.0). Conclusion: EP supplementation of a RN advice service has the potential to reduce ED visits by almost 15% while providing excellent safety and satisfaction.

Introduction: Over 700 different input, throughput and output metrics have been used to quantify ED crowding. Of these, only ED length-of-stay (ED LOS) has been shown to be associated with mortality. No comparative evaluation of ED crowding metrics has been performed to determine which ones have the strongest association with patient mortality. The objective of this study was to compare the strength of association of common ED input, throughput and output metrics to patient mortality. Methods: Administrative data from five years of ED visits (2011-2014) at three urban EDs were linked to develop a database of over 900,000 ED visits with patient demographics, electronic time stamps for care processes, dispositions and outcomes. The data were randomly divided into three partitions of equal size. Here we report the findings from one partition of 253,938 ED visits. The remaining two data partitions will be used to validate these findings. Commonly-used crowding metrics were quantified and aggregated by day or by shift (0800-1600, 1600-2400, 2400-0800), and the shift-specific metrics assigned to each patient. The primary outcome was 7-day all-cause mortality. Multilevel logistic regression models were developed for 7-day mortality, with selected ED crowding metrics and a common set of confounders as predictors. The strength of association between the crowding metrics and mortality was compared using Akaike’s Information Criterion (AIC) and the Bayesian Information Criterion (BIC): ED crowding metrics with lower AIC and BIC have stronger associations with 7-day mortality. Results: Of 909,000 ED encounters, 124,679 (16.5%) arrived by EMS, 149,233(19.7%) were admitted, and 3,808 patients (0.5%) died within 7 days of ED arrival. Of input metrics, the model with ED wait-time was better (i.e. had a smaller AIC and BIC) than models for daily census, ED occupancy or LWBS proportion for predicting 7-day mortality. Of throughput metrics, the model with mean ED LOS was better than the model for mean MD care time. Of output metrics, the model with daily inpatient hospital occupancy was better than the model with mean boarding time. Conclusion: Based on one data partition, regression models based on the average wait-time, ED LOS and inpatient occupancy best predicted 7-day mortality. These results will be validated in the two other data partitions to confirm the best-performing ED input, throughput and output metrics.

Introduction: Emergency department (ED) access block is the #1 safety concern in Canadian EDs. Its main cause is hospital access block, manifested by prolonged boarding of inpatients in EDs. Hospital administrators often believe this problem is too big to be solved and would require large increases in hospital capacity. Our objective was to quantify ED access gap by estimating the cumulative hours that CTAS 1-3 patients are blocked in waiting areas. This value, expressed as a proportion of inpatient care capacity, is an estimate of the bed hours a hospital would have to find in order to resolve ED access. Methods: A convenience sample of urban Canadian ED directors were asked to provide data summarizing their CTAS 1-3 inflow, the proportion triaged to nursed stretchers vs. RAZ or Intake areas, and time to care space. Total ED access gap was calculated by multiplying the number of CTAS 1-3 patients by their average delay to care space. Time to stretcher was captured electronically at participating sites, but time to RAZ or intake spaces was often not. In such cases, respondents provided time from triage to first RN or MD assessment in these areas. The primary outcome was total annual ED access block hours for emergent-urgent patients, expressed as a proportion of funded inpatient bed hours. Results: Directors of 40 EDs were queried. Six sites did not gather the data elements required. Of 34 remaining, 29 (85.3%) provided data, including 15 tertiary (T), 10 community (C) and 2 pediatric (P) sites in 12 cities. Mean census for the 3 ED types was 72,308 (T), 58,849 C) and 61,050 (P) visits per year. CTAS 1-3 patients accounted for 73.4% (T), 67.7% (C) and 66.2% (P) of visits in the 3 groups, and 34% (T), 46% (C) and 44% (P) of these patients were treated in RAZ or intake areas rather than staffed ED stretchers. Mean time to stretcher/RAZ care was 50/71 min (T), 46/62 min (C), and 37/59 min (P). Average ED access gap was 47,564 hrs (T), 37,222 hrs (C) and 35,407 hrs (P), while average inpatient bed capacity was 599 beds (5,243,486 hrs), 291 beds (2,545,875 hrs) and 150 beds (1,314,000 hrs) respectively. ED access gap as a proportion of inpatient care capacity was 0.93% for tertiary, 1.46% for community and 2.69% for pediatric centres. Conclusion: ED access gap is very large in Canadian EDs, but small compared to hospital operating capacity. Hospital capacity or efficiency improvements in the range of 1-3% could profoundly mitigate ED access block.

Introduction/Innovation Concept: University Departments of Emergency Medicine are responsible for the supervision of research and other scholarly projects for fellows, residents and students, though often lack resources to provide adequate input and oversight. Many departments cover large geographical areas and several programs. We piloted new research committee structures and processes to improve oversight and output of research projects. Methods: We created an interactive group supervision tool based around formation of a collaborative research committee, with rotating chairs from each program, to provide supervision and face to face interaction, and direction for research learners. Included were all Dalhousie University adult and pediatric emergency medicine residency and fellowship programs, as well as trauma and EMS programs across Nova Scotia, New Brunswick, and Prince Edward Island. In addition to providing expertise in clinical trial coordination, database management, research administration, grant applications and Research Ethics Board submissions, we have completed a 2-year pilot of our interactive group supervision tool for research projects. Curriculum, Tool, or Material: The interactive tool consists of a structured PICOD form; allocation of topic and research mentors; standardized yearly milestones from project development through presentation and publication; and regular video-conferenced and in-person interactive group sessions involving several project leads, as well as program research directors, researchers, and co-ordinators. To date, all participating program learners have engaged with the tool, with positive feedback from learners, supervisors and program directors. Conclusion: We report our development of a regional collaborative interactive group supervision tool, that maximizes expert resources in the provision of research and scholarly project supervision.

Introduction/Innovation Concept: Student Run Simulation Team (SRST) is an extracurricular medical student group that provided peers with opportunities to learn and teach principles of acute care medicine in a simulated environment. Early exposure to simulation has been identified as a way for medical students to engage in self-directed education. SRST operated through a peer-led model. Senior medical students designed and delivered didactic sessions, simulation scenarios, and debriefed the scenarios to emphasise targeted objectives. Methods: Informal interviews conducted by the SRST as part of a needs analysis identified barriers to an effective transition from pre-clerkship to clerkship. Specifically, principles of team dynamics including effective communication and role clarification in emergency situations were identified as areas where students lacked confidence. The curriculum focused on leadership and an effective team approach to common acute presentations. SRST members acquired simulation skills under the guidance of a simulation team at the University of Calgary. In the inaugural year, 8 second year students developed and delivered the curriculum to 16 first year students. Quality improvement surveys and participant feedback contributed to ongoing program review and refinement. Curriculum, Tool, or Material: Didactic lectures and task-trainer based skills sessions were created to assist the medical students in developing a foundational approach to a patient presenting to the emergency department. Three distinct simulations of increasing complexity were designed for students to build on their skills. SRST members worked with simulation consultants during 4 custom designed training sessions to develop simulation skills (design and debriefing). The distinguishing aspect of SRST is an emphasis on the non-technical skills of teamwork, leadership, and communication, rather than knowledge acquisition alone. The structure also included a succession plan for continued peer-led education where the student participants will form the next year’s team and will receive similar simulation education. Conclusion: SRST is the first student-run simulation initiative to be established in a Canadian medical school. This near-peer team allowed for early practice of non-technical skills in emergency settings. SRST facilitated opportunities for simulation education for both the junior students as participants, and the senior medical students as educators. This is an ongoing initiative, with plans to continue program development in future years.

Introduction: Research supports the role of mentors in the personal development and career advancement of medical trainees. Compared to non-mentored peers, mentored residents are nearly twice as likely to describe excellent career preparation and demonstrate objective career success. In prior research, only 65% of training programs in Canada had a mentorship program, and 40% indicated a need for more formal mentorship models. Methods: A needs assessment survey was distributed to RCPSC Emergency Medicine (EM) Program Directors across Canada regarding mentorship available to resident physicians training at their centers. Additionally, all EM resident and staff physicians involved in mentorship were surveyed on their perceptions of current models at their institutions. Both surveys were comprised of binary, open ended, and 5 point likert scale questions. Responses were analyzed using Fisher’s exact test. Results: Eleven Program Directors responded to the survey. Formal mentorship programs were found in 82% of training centers, with 77% of programs instituted within the past 5 years. Half of resident/mentor pairings were based on a combination of identified career goals, participant personality traits, or resident request. Other pairing methods included perceived resident needs or attending physician request. Most meetings are face-to-face, with one program requiring mutual scheduled shifts. Residents identified that mentorship was significantly associated with benefits to career (p=0.0016) and niche (p=0.0019) development. Formal mentorship was felt to have a significant association with resident academic development (p=0.05) and lower rates of burnout (p=0.0018) by staff physicians. Staff mentors also associated a personal development benefit related to involvement in a mentorship relationship (p=0.0355). Conclusion: The majority of EM programs have adopted formal mentorship programs within the past 5 years. Residents and staff identify that mentorship relationships are associated with improved career and niche development as well as academic advancement. Future research will include a before and after study of the implementation of a formal mentorship program within the RCPSC-EM program at the University of Manitoba.

Introduction/Innovation Concept: Utilization of CT imaging has increased dramatically over the past two decades, but has not necessarily improved patient outcomes. As healthcare spending grows unsustainably and evidence of harms from unnecessary testing accrues, there is pressure to improve imaging appropriateness. However, prior attempts to reduce unnecessary imaging using evidence-based guidelines have met with limited success, with common barriers cited including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. This project attempts to address these barriers through the development of an electronic clinical decision support (CDS) tool embedded in clinical practice. Methods: An interactive web-based point-of-care CDS tool was incorporated into computerized physician order entry software to provide real-time evidence-based guidance to emergency physicians for select clinical indications. For patients with mild traumatic brain injury (MTBI), decision support for the Canadian CT Head Rule pops up when a CT head is ordered. For patients with suspected pulmonary embolism (PE), the tool is triggered when a CT pulmonary angiogram is ordered and provides CDS for the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT imaging. To study the impact of the tool, all emergency physicians in the Calgary zone were randomized to receive voluntary decision support for either MTBI or PE. Curriculum, Tool, or Material: The tool uses a multifaceted approach to inform physician decision making, including visualization of risk and quantitative outcomes data and links to primary literature. The CDS tool simultaneously documents guideline compliance in the health record, generates printable patient education materials, and populates a REDCap™ database, enabling the creation of confidential physician report cards on CT utilization, appropriateness and diagnostic yield for both audit and feedback and research purposes. Preliminary data show that physicians are using the MTBI CDS approximately 30% of the time, and the PE CDS approximately 40% of the time. Evaluation of CDS impact on imaging utilization and appropriateness is ongoing. Conclusion: A voluntary web-based point-of-care decision support tool embedded in workflow has the potential to address many of the factors typically cited as barriers to use of evidence-based guidelines in practice. However, high rates of adherence to CDS will likely require physician incentives and appropriateness measures.

Introduction: Resuscitative clinician-performed transesophageal echocardiography (TEE) is a relatively new ultrasound application that has the potential to guide the management of critically ill patients in the emergency department. The objective of this study was to determine the effectiveness of a brief training workshop for teaching a resuscitative TEE protocol to emergency medicine residents using a simulator. Methods: Emergency medicine residents with no prior TEE experience from a university-affiliated hospital were invited to participate in the study. Participants completed a questionnaire and baseline skill assessment using a high-fidelity simulator. The training session included a 20-minute lecture followed by 10 simulated repetitions of a 5-view TEE sequence with instructor feedback. Learning was evaluated by a skill assessment immediately after training and a transfer test 1-2 weeks after the training session. Ultrasound images and transducer motion metrics were captured by the simulator for blinded analysis. The primary outcome of this study was the percentage of successful views before and after training. Secondary outcomes included confidence level, image quality, percentage of correct diagnoses, and efficiency of movement. Assessment scores were compared using a two-tailed t-test. Results: 10 of 11 (91%) of invited residents agreed to participate in the study. Confidence level on a 10-point numeric rating scale (NRS) increased from a baseline of 1.0 (SD 0) to 7.0 (SD 1.9) after training (p<0.01). The mean duration between training and transfer test was 9.6 days (SD 1.9). The percentage of successful views increased from 44% at baseline to 100% after training, and 90% on the transfer test (p<0.01). The mean image quality on a 5-point scale was 2.2 (SD 1.0) at baseline, 3.8 (SD 0.7) after training (p<0.01), and 3.1 (SD 0.6) on the transfer test (p<0.01). The mean number of transducer accelerations were 524 (SD 202) at baseline, 219 (SD 54) after training (p<0.01), and 400 (SD 149) on the transfer test (p=0.13). Participants made the correct diagnosis in 70% of cases on the transfer test. Conclusion: After a brief training session using a simulator, emergency medicine residents were able to generate adequate TEE images on a delayed transfer test. Future studies are needed to determine effective strategies for maintaining motion efficiency and imaging quality.

Introduction: The Institute of Medicine (IOM) has recommended that high-quality, evidence-based guidelines be developed for emergency medical services (EMS). The National Association of EMS Physicians (NAEMSP) has outlined a strategy that will see this task fulfilled, consisting of multiple working groups focused on all aspects of guideline development and implementation. A first step, and our objective, was a cataloguing and appraisal of the current guidelines targeting EMS providers. Methods: A systematic search of the literature was conducted in MEDLINE (1175), EMBASE (519), PubMed (14), Trip (416), and guidelines.gov (64) through May 1, 2016. Two independent reviewers screened titles for relevance to prehospital care, and then abstracts for essential guideline features, including a systematic review, a grading system, and an association between level of evidence and strength of recommendation. All disagreements were moderated by a third party. Citations meeting inclusion criteria were appraised with the AGREE II tool, which looks at six different domains of guideline quality, containing a total of 23 items rated from 1 to 7. Each guideline was appraised by three separate reviewers, and composite scores were calculated by averaging the scaled domain totals. Results: After primary (kappa 97%) and secondary (kappa 93%) screening, 49 guidelines were retained for full review. Only three guidelines obtained a score of >90%, the topics of which included aeromedical transport, analgesia in trauma, and resuscitation of avalanche victims. Only two guidelines scored between 80% and 90%, the topics of which included stroke and pediatric seizure management. One guideline, splinting in an austere environment, scored between 70% and 80%. Nine guidelines scored between 60% and 70%, the topics of which included ischemic stroke, cardiovascular life support, hemorrhage control, intubation, triage, hypothermia, and fibrinolytic use. Of the remaining guidelines, 14 scored between 50% and 60%, and 20 obtained a score of <50%. Conclusion: There are few high-quality, evidence-based guidelines in EMS. Of those that are published, the majority fail to meet established quality measures. Although a lack of randomized controlled trials (RCTs) conducted in the prehospital field continues to limit guideline development, suboptimal methodology is also commonplace within the existing literature.

Introduction: Data regarding adverse events (AEs) (unintended harm to the patient from health care provided) among children seen in the emergency department (ED) are scarce despite the high risk setting and population. The objective of our study was to estimate the risk and type of AEs, and their preventability and severity, among children treated in pediatric EDs. Methods: Our prospective cohort study enrolled children <18 years of age presenting for care during 21 randomized 8 hr-shifts at 9 pediatric EDs from Nov 2014 to October 2015. Exclusion criteria included unavailability for follow-up or insurmountable language barrier. RAs collected demographic, medical history, ED course, and systems level data. At day 7, 14, and 21 a RA administered a structured telephone interview to all patients to identify flagged outcomes (e.g. repeat ED visits, worsening/new symptoms, etc). A validated trigger tool was used to screen admitted patients’ health records. For any patients with a flagged outcome or trigger, 3 ED physicians independently determined if an AE occurred. Primary outcome was the proportion of patients with an AE related to ED care within 3 weeks of their ED visit. Results: We enrolled 6377 (72.0%) of 8855 eligible patients; 545 (8.5%) were lost to follow-up. Median age was 4.4 years (range 3 months to 17.9 yrs). Eight hundred and seventy seven (13.8%) were triaged as CTAS 1 or 2, 2638 (41.4%) as CTAS 3, and 2839 (44.7%) as CTAS 4 or 5. Top entrance complaints were fever (11.2%) and cough (8.8%). Flagged outcomes/triggers were identified for 2047 (32.1%) patients. While 252 (4.0%) patients suffered at least one AE within 3 weeks of ED visit, 163 (2.6%) suffered an AE related to ED care. In total, patients suffered 286 AEs, most (67.9%) being preventable. The most common AE types were management issues (32.5%) and procedural complications (21.9%). The need for a medical intervention (33.9%) and another ED visit (33.9%) were the most frequent clinical consequences. In univariate analysis, older age, chronic conditions, hospital admission, initial location in high acuity area of the ED, having >1 ED MD or a consultant involved in care, (all p<0.001) and longer length of stay (p<0.01) were associated with AEs. Conclusion: While our multicentre study found a lower risk of AEs among pediatric ED patients than reported among pediatric inpatients and adult ED patients, a high proportion of these AEs were preventable.

Introduction: Children with moderate cellulitis are often treated with IV antibiotics in the hospital setting, as per recommendations. Previously in our hospital, a protocol using daily IV ceftriaxone with follow-up at the day treatment center (DTC) was used to avoid admission. In 2013, a new protocol was implanted and suggested the use of high dose (HD) oral cephalexin with follow-up at the DTC for those patients. The aim of this study was to evaluate the safety and efficacy of the HD cephalexin protocol to treat moderate cellulitis in children as outpatient. Methods: A retrospective chart review was conducted. Children were included if they presented to the ED between January 2014 and 2016 and were diagnosed with a moderate cellulitis sufficiently severe to request a follow up at DTC and who were treated according to the standard of care with the HD oral cephalexin (100 mg/kg/day) protocol. Descriptive statistics for clinical characteristics of patients upon presentation, as well as for treatment characteristics in the ED and DTC were analyzed. Treatment failure was defined as: need for admission at the time of DTC evaluation, change for IV treatment in DTC or return visit to the ED. Outcomes were compared to historic controls treated with IV ceftriaxone at the DTC, where admission was avoided in 80% of cases. Results: During the study period, 682 children with cellulitis were diagnosed in our ED. Of these, 117 patients were treated using the oral HD cephalexin outpatient protocol. Success rate was 89.5% (102/114); 3 patients had an alternative diagnosis at DTC. Treatment failure was reported in 12 cases; 10 patients (8.8%) required admission, one (0.9%) received IV antibiotics at DTC, and one (0.9%) had a return visit to the ED without admission or change to the treatment. This compares favorably with the previous study using IV ceftriaxone (success rate of 80%). No severe deep infections were reported or missed; 4 patients required drainage. The mean number of visits per patient required at the DTC was 1.6. Conclusion: Treatment of moderate cellulitis requiring a follow-up in a DTC, using an oral outpatient protocol with HD cephalexin is a secure and effective option. By reducing hospitalization rate and avoiding the need for painful IV insertion, HD cephalexin is a favourable option in the management of moderate cellulitis for pediatric patients, when no criteria of toxicity are present.

Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment & observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment & treatment. A CDU was established at BC Children’s Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED. Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted & entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED & b) the number of RTED that were clinically unnecessary. Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) & therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) & families’ understanding of disease symptom range & duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of >8 hours, thus were considered averted hospitalizations attributable to the CDU. Conclusion: The CDU has had a positive impact on patient & system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary & 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.

Introduction/Innovation Concept: Emergency departments (ED) across Canada have experienced increased patient volumes and greater demands on resources. Quality improvement (QI) projects have become common in the ED with the goal of providing better and more efficient care. These projects typically attempt to improve resource utilization or patient experience. Unfortunately, the opportunity to share and exchange information among physicians about QI projects is limited. The Free Open Access Medical Education (FOAMed) domain provides a good opportunity for physicians to share their successes and challenges when implementing QI projects. The Featured Leadership & Organizational Workplace (FLOW) Hacks is an ongoing dissemination project hosted on CanadiEM.org that aims to provide ED physicians with a forum for knowledge exchange and transfer. Methods: Emergency physician leaders from across Canada have been recruited to share their QI experiences. The FLOW Hacks are summarized as a standardized set of questions that aim to convey the most important aspects of the QI project. The physician responses are published on a monthly basis as a feature on the site. Our objective is to represent EDs from across Canada and of variable size. Curriculum, Tool, or Material: Our standardized questions collect information not only on the innovation and team members but also the methodology used for the QI initiative, the data collected, and the performance measures used to assess the outcome. There is a particular focus placed on the challenges that were encountered in implementing the initiative, how they were overcome, and how they would change their approach if they could redo the project. The goal of this format is to showcase the best QI initiatives in Canada so that others can replicate the work and learn from the challenges and success of the authors. Conclusion: The FLOW Hacks series is an innovative project to disseminate QI projects to emergency physicians and managers. In the next phase of this project we will conduct a qualitative analysis of the published FLOW Hacks to identify the common mistakes and best practices in implementation of QI initiatives.

Introduction/Innovation Concept: Free Open Access Medical Education (FOAM) is an emerging movement enabling crowdsourced sharing of vast amounts of medical knowledge on the web, especially in the dynamic field of emergency medicine (EM). However, the wide range of FOAM producers and the lack of organization in published FOAM content results in a challenge for learners to find quality resources that meet their educational needs. ILearnEM addresses this by curating content from popular FOAM sites to provide both new and seasoned learners with an organized, topic-structured EM curriculum. Methods: The resources on ILearnEM.com are drawn from the top 50 scoring websites on the Social Media Index (SMI), an indirect measure of quality and impact for online educational resources. The quality of each individual resource is reviewed by our curators using published Quality Checklists developed specifically for FOAM. Links to the original resources are systematically organized into core EM topics and separated into “Approach to” and “Beyond the Basics” categories. Curriculum, Tool, or Material: Since its launch in February 2016, ILearnEM.com has been distributed to the University of Ottawa medical students and residents, the Canadian CCFP-EM program directors, and through social media. Content on the website is updated every two weeks by our curators through an analysis of recent online publications from each of the top 50 SMI sites. The new resources are selected based on the level of quality and the relevance to the fundamentals of EM. Content updates are announced on social media (Twitter) to further engage learners by identifying the availability of new material. Conclusion: Based on a 10-month traffic analysis, 4234 unique visitors visited ILearnEM.com with an average of 1.9 visits/person and 10.4 pages/visit. Of those responding to an online survey (n=138, response rate=3.3%) visitors were 42.8% (n=59) residents, 29.0% medical students (n=40), 19.6% practicing physicians (n=27), and 8.7% other healthcare professionals (n=12). As one of few sites with an objective for a learner-oriented approach to curating content, ILearnEM will continue to be updated regularly based on user feedback to benefit the fast growing consumer base of medical student and resident learners.

Introduction/Innovation Concept: The boom in online educational resources for medical education over the past decade has changed how physicians learn and keep up to date with new literature. While nearly all emergency medicine residents use online resources, few of these resources were designed to target knowledge gaps. Novel methods are required to identify learning needs to allow the targeted development of learner-centered curricula. Methods: A multidisciplinary team attempted to determine the feasibility of conducting a Massive Online Needs Assessment (MONA) to assess the perceived and unperceived educational needs in thrombosis and bleeding. An open, online survey was launched via Google Forms and disseminated using the online educational resource CanadiEM.org and social media platforms Twitter and Facebook with the goal of reaching participants of the Free Open Access Medical education (FOAM) community. Curriculum, Tool, or Material: The survey was designed to identify knowledge gaps and contained demographic, free text, and multiple choice questions. It took individuals approximately 30 minutes to complete and was incentivized with entry into a draw for one of four $250 Amazon Gift cards. Feasibility was defined a priori as 150 responses from at least 4 specialties in 4 or more countries. This sample was deemed the minimum number required to identify knowledge gaps (defined as <50% correct answers). The survey was open from September 20 to December 10, 2016. We received 198 complete responses from 20 countries. Respondents included staff physicians (n=109), residents (n=46), medical students (n=29), nurses (n=8), paramedics (n=4), a pharmacist (n=1) and a physician assistant (n=1). The survey entry page hosted on CanadiEM.org received page views from 866 unique IP addresses. As such, a conservative approximation of the completion rate per unique viewer was 22% (198/866). Conclusion: It is feasible to use a MONA to collect data on the perceived and unperceived needs of an online community. Such needs assessments could be used to make online resources more learner-centered.

Introduction: The majority of syncope patients transported to the emergency department (ED) by emergency medical services (EMS) are low-risk with very few suffering serious adverse events (SAE) within 30-days and over 50% are diagnosed with vasovagal syncope. These patients can potentially be diverted by EMS to alternate pathways of care (primary care or syncope clinic) if appropriately identified. We sought to identify high-risk factors associated with SAE within 30-days of ED disposition as a step towards developing an EMS clinical decision tool. Methods: We prospectively enrolled adult syncope patients who were transported to 5 academic EDs by EMS. We collected standardized variables at EMS presentation from history, clinical examination and investigations including ECG and ED disposition. We also collected concerning symptoms identified and EMS interventions. Adjudicated SAE included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, hemorrhage and procedural interventions. Multivariable logistic regression was used for analysis. Results: 990 adult syncope patients (mean age 58.9 years, 54.9% females and 16.8% hospitalized) were enrolled with 137 (14.6%) patients suffering SAE within 30-days of ED disposition. Of 42 candidate predictors, we identified 5 predictors that were significantly associated with SAE on multivariable analysis: ECG abnormalities [OR=1.77; 95%CI 1.36-2.48] (non-sinus rhythm, high degree atrioventricular block, left bundle branch block, ST-T wave changes or Q waves), cardiac history [OR=2.87; 95%CI 1.86-4.41] (valvular or coronary heart disease, cardiomyopathy, congestive heart failure, arrhythmias or device insertions), EMS interventions or concerning symptoms [OR=4.88; 95%CI 3.13- 7.62], age >50 years [OR=3.18; 95%CI 1.68-6.02], any abnormal vital signs [OR=1.58; 95%CI 1.03-2.42] (any EMS systolic blood pressure >180 or <100 mmHg, heart rate <50 or >100/minute, respiratory rate >25/minute, oxygen saturation <91%). [C-statistic: 0.81; Hosmer Lemeshow p=0.30]. Conclusion: We identified high-risk factors that are associated with 30-day SAE among syncope patients transported to the ED by EMS. This will aid in the development of a clinical decision tool to identify low-risk patients for diversion to alternate pathways of care.