Introduction: Almost every domain of quality is reduced in crowded emergency departments (ED), with significant challenges around the definition, measurement and interventions for ED crowding. We wished to determine if a combination of 3 easily measurable variables could perform as well as standard tools (NEDOCS score and a NEDOCS-derived LOCAL tool) in predicting ED crowding at a tertiary hospital with 57,000 visits per year. Methods: Over a 2-week period, we recorded ED crowding predictor variables and calculated NEDOCS and LOCAL scores. These were compared every 2 hours to a reference standard Physician Visual Analog Scale (range 0 to 10) impression of crowding to determine if any combination of variables outperformed NEDOCS and LOCAL (crowded=5 or greater). Five numeric variables performed well under univariate analysis: i) Total ED Patients; ii) Patients in ED beds + Waiting Room; iii) Boarded Patients; iv) Waiting Room Patients; v) Patients in beds To Be Seen. These underwent multivariate, log regression with stratification and bootstrapping to account for incomplete data and seasonal and daily effect. Results: 143 out of a possible 168 observations were completed. Two different combinations of 3 variables outperformed NEDOCS and LOCAL. The most powerful combination was: Boarded Patients; plus Waiting Room Patients; plus Patients in beds To Be Seen, with Sensitivity 81% and Specificity 76% (r=0.844, β=0.712, p<0.0001, strong positive correlation). This compared favourably with NEDOCS and LOCAL, each with Sensitivity 71% and Specificity 64%[PA1] (r=0.545 and r=0.640 respectively). We will also present a sensitivity and specificity analysis of all combinations of predictor variables, using various reference standard cut-offs for crowding. Conclusion: A combination of 3 easily measurable ED variables (Boarded Patients; plus Waiting Room Patients; plus Patients in beds To Be Seen) performed better than the validated NEDOCS tool and a NEDOCS-derived LOCAL score at predicting ED crowding. Work is on going to design a simple tool that can predict crowding in real time and facilitate early interventions. Correlation with ED system and clinical outcomes should be studied in different ED environments.

Introduction: Patients with advanced malignant and non-malignant disease (advanced disease—AD) who do not want or benefit from aggressive resuscitation may unfortunately receive such treatments if unable to communicate in an emergency. Timely access to patients’ resuscitation wishes is imperative for treating physicians and for medical information systems. Our aim was to determine what proportion of emergency department (ED) patients with AD have accurate, readily accessible resuscitation status documentation. Methods: This cross-sectional, prospective study was conducted at a tertiary care ED during purposefully sampled random accrual times in summer 2016. We enrolled all patients with: 1) palliative care consultation, 2) metastatic malignancy, 3) COPD or CHF on home oxygen, 4) hemodialysis, or 5) advanced neurodegenerative disease/dementia. The primary outcome was the retrieval of any existing resuscitation status documents. Documentation was obtained from a standardized review of forms accompanying the patient (“arrival documents”) and electronic medical record (“EMR”). We measured the time to retrieve this documentation, and interviewed consenting patients to corroborate documentation with their current wishes. Results: Of 85 enrolled patients, only 33 (39%) had any documentation of resuscitation status: 28 (33%) had goals of care retrieved from the hospital EMR, and 11 (15%) from arrival documents (some had both). Patients from long-term care facilities were more likely to have documentation available (odds ratio 13 [95% CI 2.5-65] vs community-living). Of 32 patients who were able to be interviewed, 20 (63%) expressed “do not resuscitate” wishes. Ten of these 20 lacked any documents to support their expressed resuscitation wishes. Previously expressed resuscitation wishes took more than 5 minutes to be retrieved in 3 cases when not filed “one click deep” in our EMR. Conclusion: The majority of patients with AD, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have goals of care documents readily available upon arrival to the ED. Patients living in the community with AD appear to be at high risk for unwanted resuscitative treatments should they present to hospital in extremis. Having documentation of their goals of care that is easily retrievable from the EMR shows promise, though issues of retrieval, accuracy, and validity remain important considerations.

Introduction: Previous studies have shown a link between Emergency Department (ED) overcrowding and worse clinical outcomes, increased risk of in-hospital mortality, higher costs, and longer times to treatment. Prolonged ED Length of Stay (LoS) of admitted patients awaiting a bed on in-patient units has been identified as a major driver of ED overcrowding. The purpose of this study is to provide a descriptive analysis of ED LoS among admitted patients, and determine the impact of prolonged ED LoS on total hospital in-patient length of stay (IP LoS). Methods: We conducted a single-site retrospective study for the period between January 1-December 31, 2015 at a very high volume community hospital. All patients aged ≥18 years admitted from the ED to acute in-patient Medicine units were identified. We carried out overall descriptive analysis (including analysis of day-of-the-week variability) on ED LoS. The mean total IP LoS for those patients with ED LoS<12 hours, 12-24 hours, and ≥24 hours were calculated and analyzed using ANOVA and Tukey HSD tests. Results: A total of 6,961 individuals were admitted to the medical units over the 12-month period. The median and mean ED LoS for admitted patients were 22.9 hrs (IQR: 13.9 hrs- 33.1 hrs) and 25.6 hrs respectively. Using ANOVA, there was a statistically significant difference in means of ED LoS as a function of the day of the week (p<0.0001), with Mondays having the highest mean ED LoS (27.6 hrs), and Fridays having the lowest (23.1 hrs). The mean IP LoS for those with ED LoS<12 hours, 12-24 hours, and ≥24 hours, were 6.8 days, 6.9 days, and 8.5 days respectively, with a statistically significant difference between group means (p<0.0001). Multiple pairwise comparisons of group means showed a statistically significant (p<0.05) difference between mean IP LOS of those with an EDLOS≥24 hours and those with an EDLOS<24 hours. Conclusion: Preliminary results indicate that ED LoS≥24 hours among admitted patients was associated with an increase in total IP LoS.*In the next 1-2 months, we intend to explore the role of other independent variables (age, sex, comorbidity, isolation status, and telemetry) on total ED LoS, and its association with IP LoS.

Introduction: Improving emergency department productivity has been a priority across Canada. In the United States, medical scribes have been utilized to increase the number of patients seen per hour (PPH) per physician; however, it is not well known if these outcomes can be translated to Canada. The purpose of this pilot evaluation was to (a) establish proof-of-concept of medical scribes in Canada and (b) gain experience in scribe implementation so as to inform future directions for the use of scribes in Canada. It was hypothesized that use of medical scribes would result in a greater PPH per physician. Methods: We conducted a four-month pilot evaluation of medical scribes in the emergency department of the Queensway-Carleton Hospital in Ottawa, Ontario. Eleven scribes were utilized in the study ranging in age from 18 to 23 years old. Following scribe training and an initial two-month acclimation period for both scribes and physicians, data collection began January 2015. Twenty-two full or part time emergency physicians were followed in this study, who received shifts with and without a scribe over the next four months. Physician work hours as well as the number of patients seen by each physician on each shift was documented. From these metrics, PPH per physician was calculated for each shift. Across the four months, the average PPH was determined for each physician during shifts with a scribe and shifts without a scribe. Two-tailed paired-samples t-tests (α=0.05) were used to compare mean (SD) PPH within physicians based on presence or absence of a scribe. Results: A total of 463 physician hours were documented without use of a scribe and 693.75 physician hours were documented with use of a scribe. Across all 22 physicians in the study, 18 (81.8%) demonstrated a greater PPH with use of a scribe. Overall, PPH per physician was significantly greater (12.9%) during shifts with a scribe (mean 2.81, SD 0.78) compared to shifts without a scribe (mean 2.49, SD 0.60) (p=0.006). Sensitivity analyses revealed that PPH per physician during shifts without a scribe during the study period were similar to the year prior, before scribes were introduced to the hospital (p=0.315). Conclusion: Use of medical scribes resulted in an increased PPH per physician in our hospital. While these results were from an evaluation at a single centre, they support broader implementation and evaluation of scribes in more centres across Canada.

Introduction: Burnout rates for emergency physicians (EP) continue to be amongst the highest in medicine. One of the commonly cited sources of stress contributing to disillusionment is bureaucratic tasks that distract EPs from direct patient care in the emergency department (ED). The novel position of Physician Navigator was created to help EPs decrease their non-clinical workload during shifts, and improve productivity. Physician Navigators are non-licensed healthcare team members that assist in activities which are often clerical in nature, but directly impact patient care. This program was implemented at no net-cost to the hospital or healthcare system. Methods: In this retrospective study, 6845 clinical shifts worked by 20 EPs over 39 months from January 1, 2012 to March 31, 2015 were evaluated. The program was implemented on April 1, 2013. The primary objective was to quantify the effect of Physician Navigators on measures of EP productivity: patient seen per hour (Pt/hr), and turn-around-time (TAT) to discharge. Secondary objectives included examining the impact of Physician Navigators on measures of ED throughput for non-resuscitative patients: emergency department length of stay (LOS), physician-initial-assessment times (PIA), and left-without-being-seen rates (LWBS). A mixed linear model was used to evaluate changes in productivity measures between shifts with and without Physician Navigators in a clustered design, by EP. Autoregressive modelling was performed to compare ED throughput metrics before and after the implementation of Physician Navigators for non-resuscitative patients. Results: Across 20 EPs, 2469 shifts before, and 4376 shifts after April 1, 2013 were analyzed. Daily patient volumes increased 8.7% during the period with Physician Navigators. For the EPs who used Physician Navigators, Pt/hr increased by 1.07 patients per hour (0.98 to 1.16, p<0.001), and TAT to discharge decreased by 10.6 minutes (-13.2 to -8.0, p<0.001). After the implementation of the Physician Navigators, overall LOS for non-resuscitative patients decreased by 2.6 minutes (1.0%, p=0.007), and average PIA decreased by 7.4 minutes (12.0%, p<0.001). LBWS rates decreased by 43.9% (0.50% of daily patient volume, p<0.001). Conclusion: The use of a Physician Navigator was associated with increased EP productivity as measured by Pt/hr, and TAT to discharge, and reductions in ED throughput metrics for non-resuscitative patients.

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The combined measure presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.

Introduction: Hip fractures affect over 35,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. The primary objective of this study was to identify risk factors independently associated with acute in-hospital delirium within 72 hours of emergency department (ED) arrival for patients diagnosed with a hip fracture. Methods: This was a retrospective chart review of patients aged 65 years and older presenting to one of two academic EDs with a discharge diagnosis of hip fracture from January 1st 2014 to December 31st 2015. Multivariable logistic regression analysis was used to determine variables independently associated with the development of acute in-hospital delirium within 72 hours of ED arrival. Results: Of the 668 included patients, mean (SD) age was 84.1 (8.0) years and 501 (75%) were female. 521 (78.0%) patients received an opioid analgesic and/or femoral nerve block in the ED. The most common analgesics used in the ED were intravenous (IV) morphine (35.8%), IV hydromorphone (35.2%), or dual therapy with both IV hydromorphone and IV morphine (2.2%). Femoral nerve blocks were initiated for 36 (5.4%) patients and successfully completed in 35 (5.2%) patients in the ED. 181 (27.1%) patients developed delirium within 72 hours of ED arrival. History of neurodegenerative disease or dementia (OR: 5.7, 95% CI: 3.9, 8.4), age >75 (OR: 2.8, 95% CI: 1.4, 5.6) and absence of analgesia in the ED (OR: 2.1, 95% CI: 1.3, 3.2) were independently associated with acute in-hospital delirium. Conclusion: The development of in-hospital delirium is common in patients diagnosed with a hip fracture. We have identified modifiable and non-modifiable risk factors independently associated with acute in-hospital delirium, which can be identified in the ED. Clinicians should be aware of these risk factors in order to implement strategies directed at reducing the development of acute delirium. Additionally, further research is needed in order to understand the relationship between analgesia delivered in the ED and the development of delirium for patients diagnosed with a hip fracture.

Introduction: We examined persons transported to hospital after police use of force to determine whether Emergency Department (ED) assessment and/or mode of transport could be predicted. Methods: A multi-site prospective consecutive cohort study of police use of force with data on ED assessment for individuals ≥18 yrs was conducted over 36 months (Jan 2010-Dec 2012) in 4 cities in Canada. Police, EMS and hospital data were linked by study ID. Stepwise logistic regression examined the relationship between the police call for service and subject characteristics on subsequent ED assessment and mode of transport. Results: In 3310 use of force events, 86.7% of subjects were male, median age 29 yrs. ED transport occurred in 26% (n=726). Odds of ED assessment increased by 1.2 (CI 1.1, 1.3) for each force modality >1. Other predictors of ED use: if the nature of police call was for Mental Health Act (MHA) (Odds 14.3, CI 10.6, 19.2), features of excited delirium (ExD) (Odds 2.7, CI 1.9, 3.7), police-assessed emotional distress (EDP) not an MHA (Odds 2.1, CI 1.5, 3.0) and combined drugs, alcohol and EDP (Odds 1.7, CI 1.9, 3.7). Those with alcohol impairment alone were less likely to go to ED from the scene: OR 0.6 (CI 0.5, 0.7). EMS transported 55% of all patients (n=401), although police transported ~100 people who EMS attended at the scene but did not subsequently transport. For patients brought to the ED, 70% had a retrievable chart (512/726) with a discernible primary diagnosis: 25% for physical injury, 32% for psychiatric and 43% for drug and/or alcohol intoxication. For use of force events that began as MHA calls, patient transport was more often by police car than ambulance OR 1.8 (CI 1.2, 2.5), while those with drug intoxication or ≥3 ExD features were more often brought by ambulance: odds of police transport 0.5 (CI 0.3, 0.9) and 0.4 (CI 0.3, 0.7). Violence or aggression did not predict mode of transport in our study. Conclusion: About one quarter of police use of force events lead to ED assessment; 1 in 4 patients transported had a physical injury of some description. Calls including the Mental Health Act or individuals with drug intoxication or excited delirium features are most predictive of ED use following police use of force. In MHA calls with use of force, persons are nearly twice as likely to go to ED by police car than by ambulance.

Introduction: Screening for depression in the emergency department (ED) has been recommended for the last two decades. It is estimated that 1 in 5 adults presenting to the ED meet the criteria for depression, making this setting an ideal point of care for proper and early referral to general practitioners and/or specialist mental health services. One of the barriers to assessment of depression in the ED is a lack of validated tools to screen for depression in this context of use. The purpose of this study is to test the extent to which the commonly used Patient Health Questionnaire (PHQ-9) is valid and reliable to screen for depression in adults presenting to the ED. Methods: Adults, aged 19 years and over, presenting to an inner-city, academic ED with an acute mental health complaint (AMHC) completed a questionnaire package that included demographic questions, the PHQ-9, and 5 other questionnaires for validation purposes. Traditional and Rasch Measurement (RM) methods were applied to the data to examine how well the items: captured the 95% range (±2 logits) of the concept of interest, were reliable and valid, and met the criteria for unidimensional and invariant measurement. Results: Preliminary prospective data from 108/200 adults (mean age 39.7±13.6 years; 65% male) completed the questionnaire package. A total of 58.9% of the sample met the criteria for moderate-severe depression (PHQ-9≥15), with 37% reporting thoughts of suicide and/or self-harm nearly every day for the past two weeks. Analysis of these items showed good overall fit to the Rasch model (χ2=28.3, df=18, p=.06), good reliability (rp=0.84), an ordered 4-point response scale structure, excellent individual item fit, and no item bias for gender, age, level of education, or employment status. Items covered between -1.45 to 1.52 logits, spanning 74% of the targeted theoretical continuum, with gaps at each end of the range. Item #3 (trouble falling or staying asleep) was the easiest item (indicating lower depression) and Items #8 and #9 (moving slowly and thoughts of harm/suicide) were the more difficult items (indicating more severe depression). Conclusion: This study supports the PHQ-9 as a reliable and valid screen for depression in the ED. Incorporating standardized and uniform assessment in Canadian EDs will begin the process of advancing the role of the ED to initiate evidence-based care to optimize the outcomes of Canadians with an AMHC.

Introduction: The risk of recurrent stroke following a transient ischemic attack (TIA) has been estimated to be as much as 5 percent in the first 48 hours and ten percent in the first week following initial TIA symptoms, but can be modified as a result of intensive risk factor management. Care pathways for these patients vary between different regions within Alberta with Edmonton admitting more TIA patients and Calgary using computed tomography angiography (CTA) based triage. To examine regional differences in the quality of care, the rate of admission for stroke within 90 days of an index ED visit for TIA/minor stroke was investigated. Methods: Data analysts from the Data Integration, Measurement and Reporting (DIMR) branch of Alberta Health Services (AHS) used the National Ambulatory Care Reporting System (NACRS) to identify patients in Alberta who were admitted for stroke within 90-days of an index emergency department (ED) visit for TIA/minor stroke from April 2010 to March 2016. Information extracted included patient demographics, region of residence (Edmonton, Calgary or non-major urban [NMU]), return diagnosis and timing of return ED visit. Analysis included descriptive summaries and proportions were compared using a χ2 test. Results: During the study period, there were 26,232 index visits to Alberta EDs for TIA/minor stroke. 5426 (26.1%) of patients were admitted on their index visit. Calgary (22.5%) had lower rates of admission on index visit followed by Edmonton (31.4%) and the NMU (46%). 20,806 (79.3%) were discharged home following their index visit. Of the patients discharged on their index visit 729 (3.5%) had an admission for stroke within 90-days of their index ED visit with rates in Edmonton (3.8%) and the NMU regions (3.8%) being significantly higher than Calgary (2.8%, p<0.01). Conclusion: Our study demonstrates significantly lower rates of admission for stroke within 90-days of ED visit for minor stroke/TIA in Calgary compared to Edmonton and the NMU. Further work should focus on validating this result and consideration of standardized care pathways that promote effective resource utilization and quality of care.

Introduction: Age and systolic blood pressure (SBP) are important predictors of Acute Cerebrovascular Syndrome (ACVS). Yet, the effect of SBP is confounded by age, making its independent contribution to ACVS risk difficult to quantify. Here we use logistic regression to explore the role of SBP in younger and older ED patients. Methods: Data comprised 1019 ED patients (ACVS 70%, 30% non-ACVS) enrolled during a 28-month period of an ongoing prospective, observational, multi-site stroke biomarker study (SpecTRA). We used logistic regression to examine the effects of age, sex, and the age:SBP interaction as predictive markers of the diagnosis of ACVS. Results: Participants (53% male) ranged in age from 18 to 97 years (Q1=58, median=70, Q3=80). SBP ranged from 84 to 248 mmHg (Q1=137, median=154, Q3=174). In our initial regression model, age, sex, SBP and the age:SBP interaction were all significant (p<0.01). Using cubic regression splines for age, sbp and their interaction yields the same conclusion (p<0.01). To better understand the role of SBP in younger vs. older patients, we stratified the sample at the median age (70 years of age). In the younger group (n=510), participants were 55% male, 60% ACVS, and had SBP ranging from 91 to 236 mmHg (Q1=133, median=148, Q3=165). In the older group (n=509), participants were 51% male, 82% ACVS and had SBP ranging from 84 to 248 mmHg (Q1=143, median=159, Q3=179), a shift of approximately 10 mmHg between the groups. The logistic regression model was then fit separately to each group without the age:SBP interaction term. In the younger group, we found SBP to be highly significant (p<0.001), with an odds-ratio (OR) of 1.18 per 10 mmHg (95% CI: 1.10-1.29). In the older group, we found that SBP was not significant (p=0.91), with an OR of 1.00 per 10 mmHg (95% CI: 0.91-1.08). Age and sex were also significant risk factors in the younger group (each p<0.01), though not in the older group (both p>0.07). Conclusion: Our findings suggest that for ED patients suspected of ACVS, SBP is a clinically relevant predictor for younger patients, with higher SBP associated with an increased risk of ACVS, regardless of patient age and sex. SBP does not appear to be a strong predictor for patients over 70. ED physicians can leverage this finding by attributing greater importance to elevated SBP in younger patients than older patients when working toward a clinical suspicion of ACVS.

Introduction: The BIG score is a new pediatric trauma score composed of the admission base deficit (BD), the international normalized ratio (INR) and the Glasgow Coma Scale (GCS). A score<16 identifies children with a high probability of survival following blunt trauma.The objective of this study was to measure the criterion validity of the BIG score to predict in-hospital mortality among children visiting an emergency department with blunt trauma requiring an admission to the intensive care unit. Methods: This was a retrospective cohort study performed in a single tertiary care pediatric hospital between 2008 and 2016. Participants were all children (<18 years) visiting the emergency department for a blunt trauma requiring intensive care unit admission or who died at the emergency department. All charts were reviewed by a member of the research team using a standardized report form. To insure quality of data abstraction, 10% of the charts were reviewed in duplicate by a second rater blinded to the first evaluation. The primary outcome was in-hospital mortality. Baseline demographics, initial components of the BIG score, Injury Severity Score (ISS) and disposition were extracted. The primary analysis was the association between a BIG score ≥16 and in-hospital mortality. It was calculated that the inclusion of at least 25 deaths would provide confidence intervals of +/- 0.20 for proportions in the worst-case scenario. Results: Twenty-eight children died among the 336 who met the inclusion criteria. The inter-rater agreement for data abstraction was excellent with kappa scores or intraclass correlation coefficients higher than 0.8 for all variables. Two hundred eighty-four children had information on the three components of the BIG score and they were included in the primary analysis. A BIG score ≥16 demonstrated a sensitivity of 0.93 (95%CI: 0.76-0.98) and specificity of 0.83 (95%CI 0.78-0.87) to identify mortality. Using ROC curves, the area under the curve was higher for the BIG score (0.97; 95%IC: 0.95-0.99) in comparison to the ISS (0.78; 95%IC: 0.71-0.85). Conclusion: The BIG score is an excellent predictor of survival for children visiting the emergency department following a blunt trauma.

Introduction: Approximately 20% of Canadians who present to emergency departments (EDs) with acute asthma relapse within 4 weeks of discharge. The reasons are likely multi-factorial; however, the lack of timely primary care provider (PCP) follow-up and inadequate patient self-management are thought to be important variables. Therefore, we tested the effectiveness of ED-directed multifaceted interventions that targeted PCPs and enhanced patient self-management to reduce asthma relapse following ED discharge. Methods: Adults with acute asthma discharged from 6 Alberta EDs were randomly allocated, in a centralized and concealed manner, to receive usual care (UC), opinion leader [OL] guidance to their PCPs, or OL guidance + nurse case-management [OL+CM] for patients (NCT01079000). The main outcome was asthma relapse within 90-days of ED discharge. Secondary outcomes included PCP visits, time to relapse, hospitalizations and asthma-related quality of life (QoL). Outcomes were collected independently and assessors were masked to intervention assignment. Results: From 943 screened patients, 367 patients were allocated to the study arms (UC=146; OL=110; OL+CM=111). Median age was 28 years, 64% were women, median peak flow at discharge was 350 L/min; 77% were discharged home on prednisone and 85% on either inhaled corticosteroids (ICS) or ICS/long-acting β2-agonists. Compared with UC, both interventions significantly increased rates of relapse at 90-days: UC=12%, OL=28%, OL+CM=19%; p=0.006. Based on an absolute increased risk of 0.16 (95% CI: 0.05, 0.25), the number needed to treat for harm was 6 (95% CI: 3.9, 19.0) for the OL arm. Across study differences in PCP follow-up visits, time to relapse, hospitalizations or asthma-related QoL were not identified. Conclusion: Two different theory-informed and evidenced-based interventions intended to decrease asthma relapse robustly and significantly increased rates of relapse compared with UC. While the reasons for these unintended consequences require further study, we caution against the adoption of similar interventions by other EDs.

Introduction: Many patients presenting to Emergency Departments (EDs) with acute asthma have limited or no access to health care providers, medications and preventive resources. This study explored outpatient care gaps among subjects presenting to the ED for acute asthma, before being discharged. Methods: Cross-sectional analysis of data obtained in a comparative effectiveness trial conducted in six EDs in Alberta (NCT01079000). Data were collected through patient interviews and chart reviews at ED presentation. Two clinician-investigators independently reviewed and adjudicated the following preventive actions: use of spacer devices, written asthma action plans (AAPs) and asthma medication; influenza immunization, cigarette smoking, and referral to asthma education. Agreement between adjudicators was calculated based on kappa (k) statistics. Results: The median age of the study population (n=367) was 28 years and 64% were women. Overall, 26% of patients reported not having a regular family physician. Agreement between reviewers was excellent (k=0.96). More than half (59%) reported not using spacer devices despite being indicated and 3% reported having a written AAP. Following the recommendations of the current asthma guidelines, 38% of the patients required the initiation of inhaled corticosteroids (ICS), 11% required the addition of ICS/long-acting β-agonists combination agents and 39% required reinforcement of adherence with preventer medications. Finally, 37% reported receiving influenza vaccination in the past year, 7% had been referred to asthma education in the last 10 years, and 31% were still smoking, suggesting that cessation counselling was indicated. Conclusion: The ED encounter for patients with acute asthma represents a unique opportunity to establish important partnerships across the continuum of asthma care (e.g., link them with a family doctor). This study provided a robust assessment of the outpatient care gaps in this patient population, which identified many areas for targeted interventions. The method of delivery and type of messaging needs further study.

Introduction: Head injuries are a commonly encountered presentation in emergency departments (ED) and the Choosing Wisely Canada (CWC) campaign was released in June 2015 in an attempt to decrease imaging utilization for patients with minor head injuries. The impact of the CWC campaign on imaging utilization for head injuries has not been explored in the ED setting. In our study, we describe the characteristics of patients with head injuries presenting to a tertiary care academic ED and the impact of the CWC campaign on CT head utilization. Methods: This retrospective cohort study used linked databases from the province of Ontario, Canada to assess emergency department visits with a primary diagnosis of head injury made between June 1, 2014 and Aug 31, 2016 at the University Health Network in Toronto, Canada. We examined the number of visits during the study period, the proportion of patients that had a CT head performed before and after the release of the CWC campaign, as well as mode of arrival, and disposition. Results: There were 4,322 qualifying visits at our site during the study period. The median presenting age was 44.12 years (IQR 27.83,67.45), the median GCS was 15 (IQR 15,15) and the majority of patients presenting had intermediate acuity (CTAS 3). Overall, 43.17% of patients arrived via ambulance, 49.24 % of patients received a CT head and 10.46% of patients were admitted. Compared to patients presenting before the CWC campaign release, there was no significant difference in the rate of CT heads after the CWC (50.41% vs 47.68%, P=0.07). There were also no significant differences between the two groups in mode of arrival (ambulance vs ambulatory) (42.94% vs 43.48%, P=0.72) or admission rates (9.85% vs 11.26%, P=0.15). However, more patients belonged to the high acuity groups (CTAS 1 or 2) in the post CWC campaign release group (12.98% vs 8.11% P<0.001). Conclusion: Visits for head injuries make up a significant proportion of total ED visits and approximately half of these patients receive CT imaging in the ED. The CWC campaign did not seem to impact imaging utilization for head injuries in the 14 months following its launch. Further efforts, including local quality improvement initiatives, are likely needed to increase adherence to its recommendation and reduce imaging utilization for head injuries.

Introduction: High-quality cardiopulmonary resuscitation (CPR) is essential for patient survival. Typically, CPR quality is only measured during the first 10 minutes of resuscitation. There is limited research examining the quality of CPR over the entire duration of resuscitation.Objective: To examine the quality of CPR over the entire duration of resuscitation and correlate the quality of CPR to patient survival. Methods: This was a retrospective observational study using data from the Toronto RescuNET Epistry-Cardiac Arrest database. We included consecutive, adult (>18) OHCA treated by EMS between January 1, 2014 and September 30, 2015. High-quality CPR was defined, in accordance with 2015 AHA Guidelines, as a chest compression rate of 100-120/min, depth of 5.0-6.0 cm and chest compression fraction (ccf) of >0.80. We further categorized high-quality resuscitation as meeting benchmarks >80% of the time, moderate-quality between 50-80% and low-quality meeting benchmarks <50% of the resuscitation. We used multivariable logistic regression to determine association between variables of interest, including CPR quality metrics, and survival to hospital discharge. Results: A total of 5,208 OHCA met our inclusion criteria with a survival rate of 8%. The median (IQR) duration of resuscitation was 23.0 min (15.0,32.7). Overall CPR quality was considered high-quality for ccf in 81% of resuscitation episodes, 41% for rate, and 7% for depth. The percentage of resuscitations meeting the quality benchmarks differed between survivors and non-survivors for both depth (15% vs 6%) and ccf (61% vs 83%) (P value <0.001). After controlling for Utstein variables maintaining a chest compression depth within recommendations for >80% showed a trend towards improved survival (OR 1.68, 95% CI 0.96, 2.92). Other variables associated with survival were public location, initial CPR by EMS providers or bystanders, witnessed cardiac arrest (EMS or bystander), and initial shockable rhythm. Increasing age and longer duration of resuscitation were associated with decreased survival. Conclusion: Overall, EMS providers were not able to maintain rate or depth within guideline recommendations for the majority of the duration of resuscitation. Maintaining chest compression depth for greater than 80% of the resuscitation showed a trend towards increased survival from OHCA.

Introduction: With one person in Canada suffering an out-of-hospital cardiac arrest (OHCA) every 12 minutes and an estimated survival to hospital discharge with good neurologic function ranging from 3 to 16%, OHCA represents a major source of morbidity and mortality. An evolving adjunct for resuscitation of OHCA patients is the use of extracorporeal membrane oxygenation-assisted CPR (ECPR). The purpose of this systematic review is to investigate the survival to hospital discharge with good neurologic recovery in patients suffering from OHCA treated with ECPR compared to those who received standard advanced cardiac life support with conventional CPR (CCPR) alone. Methods: A systematic database search of both MEDLINE & EMBASE was performed up until September 2016 to identify studies with ≥5 patients reporting ECPR use in adults (age ≥16 years) with OHCA. Only studies reporting survival to hospital discharge were included. All identified studies were assessed independently using pre-determined inclusion criteria by two reviewers. Study quality and risk of bias were evaluated using the Newcastle Ottawa regulations assessment scale. Results: Of the 1065 records identified, 54 studies met all inclusion criteria. Inter-rater reliability was high with a kappa statistic of 0.85. The majority of studies were comprised of case series (n=45) of ECPR with 5 to 83 patients/study. Out of the 45 case series, 37 presented neurologic data at hospital discharge and demonstrated a broad range of patients surviving with good neurologic outcome (0 to 71.4%). Only 9 cohort studies with relevant control group (CCPR) were identified (38 to 21750 patients/study). Preliminary analysis demonstrated that 6 cohort studies were sufficient quality to compare ECPR to CCPR. All 6 studies showed significantly increased survival to hospital discharge with good neurologic recovery (ECPR 10.6 to 41.6% vs CCPR 1.5 to 7.7%, respectively). Conclusion: Given the paucity of studies using appropriate comparators to evaluate the impact of ECMO, our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. Interestingly, a limited number of studies with suitable controls demonstrated a potential benefit associated with ECPR in the management of OHCA in selected patients. In this state of equipoise, high quality RCT data is urgently needed.

Introduction: Sleep deprivation negatively affects cognitive and behavioural performance. Emergency Medicine (EM) residents commonly work night shifts and are then expected to perform with competence. This study examines the impact of night shifts on EM resident performance in simulated resuscitation scenarios. Methods: A retrospective cohort study was completed at a single Canadian academic centre where residents participate in twice-annual simulation-based resuscitation objective structured clinical examinations (OSCEs). OSCE scores for all EM residents between 2010-2016 were collected, as well as post-graduate year (PGY1-5), gender, and shift schedules. OSCEs were scored using the Queen’s Simulation Assessment Tool (QSAT) evaluating four domains: primary assessment, diagnostic actions, therapeutic actions and communication, and an overall global assessment score (GAS). A night shift was defined as a late evening (beyond 23:00) or overnight shift within the three days before an OSCE. A mixed effects linear regression model was used to model the association between night shifts and OSCE scores while adjusting for gender and PGY. Results: A total of 136 OSCE scores were collected from 56 residents. PGY-5 residents had 37.1% (31.3 to 34.0%; p<0.01) higher OSCE scores than those in PGY-1 with an average increase of 8.8% (7.5 to 10.1%; p<0.01) per year. Working one or more night shifts in the three days before an OSCE reduced the total and communication scores by an average of 3.8% (p=0.04) and 4.5% (p=0.04) respectively. We observed a significant gender difference in the effects of acute shift work (p=0.03). Working a night shift one night prior to an OSCE was not associated with total score among male residents (p=0.33) but was associated with a 6.1% (-11.9 to -0.2; p=0.04) decrease in total score among female residents. This difference was consistent across PGY and was primarily due to an 8.5% (-15.5 to -1.6%; p=0.02) decrease in communication scores and a 6.7% (-13.1 to -0.3%; p=0.04) reduction in GAS. Conclusion: Proximity to night shifts significantly impaired the performance of EM trainees in simulated resuscitation scenarios, particularly in the domain of communication. For female residents, the magnitude of difference in total scores after working such shifts one night prior to a resuscitation OSCE was approximately equal to the difference seen between residents one year apart in training.

Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically 8-12%. Recent evidence has shown that public access automatic external defibrillators (AED) may improve survival. The objectives of this study were to determine whether AEDs improve rates of return of spontaneous circulation (ROSC), overall survival, and favourable neurological survival (FNS) in Canada. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2011-2015 within BC’s four metropolitan areas. We included all EMS-treated adult patients. Data were collected in accordance with recognized Utstein criteria. We described frequencies with counts, means and medians where appropriate, and the Z-test was used to compare population proportions. Results: We examined 7577 OHCAs from 2011-2015. AEDs were deployed on 223 patients in this period (mean age 60.4 yrs [95% CI 45.7-75.1] and 83.9% male; non-AED OHCAs mean age 66.2 yrs [48.4-83.8] and 67.3% male). Seventy seven percent of AED deployments occurred in public locations, 69.1% were witnessed by bystanders and CPR was initiated in 98.7% of these cases. Fifteen percent of non-AED OHCAs occurred in public locations, 38.3% were bystander witnessed, and 45.4% received bystander CPR. AEDs delivered shocks to 61.4% of patients, and EMS crews found an initial shockable rhythm upon scene arrival in 60.5% of AED deployments (22.9% for non-AED cases). AED OHCA patients had higher rates of ROSC at any time (67.2% vs 47.6%; difference of 19.6% [12.9-26.2 p<0.01]), and ROSC at ED arrival (61% vs 35.4%; difference of 25.6% [19.2-32.0 p<0.01]). AED OHCA patients had higher rates of survival to hospital discharge (23.8% vs 8.5%; difference 15.3% [11.5-19.1 p<0.01]). Detailed neurologic outcome data was not available for all patients, yet for those which it was available AED OHCA patients had improved outcomes (modified Rankin score<2) compared to non-AED OHCA patients (9.0% vs 5.4%; difference 3.6% [0.6-6.6 p<0.02]. Conclusion: Automatic external defibrillators markedly improve rates of ROSC at any time, sustained ROSC at ED arrival, survival to hospital discharge, and FNS in Canada. Continued support for public access AED programs is essential to improve patient outcomes.

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital after return of spontaneous circulation (ROSC). Percutaneous coronary intervention (PCI) is often indicated as a diagnostic and therapeutic procedure following OHCA. This study aimed to determine the association between the type of destination hospital (PCI-capable or not) and survival to discharge for patients with OHCA and prehospital ROSC. We hypothesized that being transported to a PCI-capable hospital would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montréal, Canada. We included adult patients with non-traumatic OHCA and prehospital ROSC. The association of interest was evaluated with a multivariate logistic regression model to control for demographic and clinical variables (age, gender, time of day, initial rhythm, witnessed arrest, bystander CPR, presence of first responders or advanced care paramedics, prehospital supraglottic airway placement, delay before paramedics’ arrival). Assuming a survival rate of 40% and 75% of the variability explained by other factors included in the model, more than 1200 patients needed to be included to detect an absolute difference of 10% in survival between both groups with a power of more than 90%. Results: A total of 1691 patients (1140 men and 551 women) with a mean age of 64 years (standard deviation 17) were included, of which 1071 (63%) were transported to a PCI-capable hospital. Among all patients, 704 patients (42%) survived to hospital discharge. We observed a significant independent association between survival to discharge and being transported to a PCI-capable hospital (adjusted odds ratio [AOR] 1.46 [95% confidence interval 1.09-1.96]) after controlling for confounding variables. Having an initial shockable rhythm and presence of first responders also increased survival to discharge (AORs 3.67 [95% confidence interval 2.75-4.88] and 1.53 [95% confidence interval 1.12-2.09], respectively). Conclusion: Patients experiencing ROSC after OHCA could benefit from a direct transport to a PCI-capable hospital. This benefit might also be related to unmeasured interventions other than PCI these hospitals can provide (e.g. high-level intensive care or cardiovascular surgery).