Introduction: Discharge from the Emergency Department (ED) is a high-risk period for communication failures. Clear verbal and written discharge instructions at patient-level health literacy are fundamental to a safe discharge process. As part of a hospital-wide quality initiative to measure and improve discharge processes, and in response to patient feedback, the St. Michael’s Hospital ED and patient advisors co-designed and implemented patient-centred discharge handouts. Methods: The design and implementation of discharge handouts was based on a collaborative and iterative approach, including stakeholder engagement and patient co-design. Discharge topics were based on the 10 most common historical ED diagnoses. ED patient advisors and the hospital’s plain language review team co-designed and edited materials for readability and comprehension. Process mapping of ED workflow identified opportunities for interventions. Multidisciplinary ED stakeholders co-led implementation, including staff education, training and huddles for feedback. Patient telephone surveys to every 25th patient presenting to the ED meeting the study inclusion criteria (16 years of age or older, directly discharged from the ED, speaks English, has a valid telephone number, and has capacity to consent) were conducted both pre- (June-Sept 2016) and post- (Oct-Dec 2016) implementation. Results: Stakeholder engagement and co-design took place over 10 months. Education was provided across one MD staff meeting, four RN inservices, and at monthly learner orientation. 44846 patients presented to the ED and 25600 met the study inclusion criteria. 935 surveys (response rate=97%; declined n=30) were completed to date. Pre-implementation (n=467), 9.2% (n=43) of patients received printed discharge materials and 71% (n=330) understood symptoms to look for after leaving the ED. Post-implementation (n=468), 44% (n=207) of patients received printed discharge materials with 97% (n=200) finding the handouts helpful and 82% (n=385) understanding symptoms to look for after leaving the ED. Conclusion: Through the introduction of patient co-designed and patient-centred discharge handouts, we have found a marked improvement in patient understanding, and consequently safer discharge practices. Future efforts will focus on optimizing discharge communication, both verbal and written, tailored to individual patient preferences.

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods: This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primary outcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results: A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71±15, 67±12, 67±13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA2DS2-VASc score was 2.6±1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA2DS2-VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p<0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p<0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion: Use of a simple OAC-prescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated.

Introduction: How is “administer a fluid bolus” interpreted by paramedics? There is no existing literature describing this practice in the prehospital setting. Paramedic medical directives authorize the administration of Normal Saline 20 ml/kg to hypotensive patients (systolic BP <90). Anecdotally, auditors of Ambulance Call Reports (ACRs) and paramedics report this amount of fluid is rarely administered. The aim of this study was to determine the amount and rate of IV fluid administered by Advanced Care (ACP) and Primary Care (PCP) paramedics when they give an IV ‘fluid bolus’ during an ambulance call. Methods: We conducted a retrospective analysis of iMedic platform, electronic, ACRs (January 01, 2015 to June 30, 2015) from 8 municipal paramedic services that serve an urban and rural population of 1.4 million. ACRs containing a procedure code 351 (intravenous fluid bolus) were identified. A stratified, random sample of 20 cases per paramedic category (ACP and PCP) from each service was generated using a random number table. ACRs were manually searched, data abstracted onto spread sheets, and the results analyzed using descriptive statistics (Wizard ver 1.8.16 for Mac). Results: The initial sample was 220 cases. 25 were excluded for incomplete documentation, leaving 195 cases (ACP 59, PCP 136) for analysis. The mean IV fluid bolus volume delivered was: ACP 414.8 ml (95%CI: 344.2, 485.4), PCP 242.3 ml (95%CI: 210.9, 274.5). The mean rate of infusion was: ACP 22.7 ml/min (95%CI: 17.6, 27.8) PCP 15.7 ml/min (95%CI 13.2,18.1). Percentage of cases where >250 ml was infused: ACP 74.6%, PCP 44.1%. Percentage of cases where at least 10 ml/kg of fluid was given: ACP 17.0%, PCP 2.9%. Percentage of cases reaching the maximum 20 ml/kg of fluid: ACP 0.5%, PCP 0%. IV cannula size: 18G-ACP 57.4%, PCP 33.3%; 20G ACP 37.0%, PCP 56.8; 22G ACP 0.6%, PCP 9.8%. Conclusion: Paramedics rarely gave the amount of IV fluid they were authorized to give to hypotensive patients. On average, Advanced Care Paramedics administered significantly more fluid and gave it significantly faster than Primary Care Paramedics. ACPs were more likely than PCPs to use 18G cannulas and rarely used 22G cannulas whereas PCPs preferred to use 20G IV cannulas. Further training is required to clarify and improve the paramedic practice of IV bolus administration.

Introduction: Best practice guidelines recommend that at least two sets of blood cultures be sent when blood cultures are required. However, high rates of solitary blood cultures are still common in the emergency department. The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the lab on patients ultimately discharged from our emergency department. Methods: This was a multi-centre, multi-phase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts. Results: The baseline rate of solitary sets of blood cultures was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a forcing function with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (P=0.071). However, the forcing function produced a statistically significant improvement (P < 0.0005), which was maintained for 6 months. Conclusion: The combination of a brief education-based intervention and a computerized forcing function was more effective than education alone in reducing solitary blood culture collection in our emergency department in this time series study. Forcing functions can be a powerful tool in modifying behaviours and processes in the clinical setting.

Introduction: Asthma is a chronic condition and exacerbations are a common reason for emergency department (ED) presentations across Canada. The objective of this study was to characterize and describe acute asthma presentations over a five-year period. Methods: Administrative health data for Alberta from 2011-2015 was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) acute asthma (ICD-10-CA: J45) ED presentations. All presentations to an Alberta ED with a primary or secondary diagnosis of acute asthma were eligible for inclusion. Presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1 were excluded. Data from NACRS were linked with a provincial diagnostic imaging database. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, a total of 51,269 (~10,000/year) acute asthma presentations were made by 34,481 patients (~0.3 presentations per patient per year). The median age was 35 years (IQR: 25, 49 years) and more patients were female (57.2%). Few patients arrived to the ED by ambulance (6.5%) and the most frequent CTAS score was 3 (43.5%). The majority of these patients (77%) had a primary diagnosis of asthma in the ED. Differences were explored between those with a primary asthma diagnosis and those with a secondary diagnosis (e.g., ambulance arrival, length of stay, hospital admission, etc.). Although differences were statistically significant, no clinically relevant differences were identified. Patients with asthma most frequently had a co-diagnosis of acute upper respiratory infection (6.2%); other co-diagnoses included bronchitis (4.7%), pneumonia (3.7%), heart failure (0.18%), pulmonary embolism (0.15%), and pneumothorax (0.03%). For 39.3% of patients, ED management included chest x-ray. The majority of patients were discharged from the ED (92.2%) following a median length of stay of 2.2 hours (IQR: 1.2, 3.8 hours). Conclusion: Acute asthma remains an important ED presentation in Alberta and the absolute frequency of presentations has remained relatively stable over the past five years. Frequency of chest x-ray ordering is high and represents a target for future interventions to reduce ionizing radiation exposure, improve patient flow and reduce healthcare costs.

Introduction: Older patients are a high-risk population in the Emergency Department (ED) for poor outcomes after ED visit, including return presentation and hospital admission. Little is known however about outcomes in older patients identified as “low acuity” by triage. We aim to describe the characteristics, ED workup, disposition, and 14-day outcomes of ED patients 65 years and up who are triaged as low acuity and compare them to a younger cohort. Methods: This health records review was done in a Canadian tertiary care ED. Included patients received a Canadian Triage Acuity score (CTAS) of 4 or 5 and were either 65 years and up (“older” group), or 40-55 years (controls). Data collected included patient demographics, tests and services involved in ED, and disposition. Return ED visit and hospital admission rates at 14 days were tracked. Data were analyzed descriptively and chi-square testing conducted to assess for differences (p < 0.05) between groups. A pre-planned stratified analysis of patients 65-74 years, 75-84, and 85 and older was conducted. Results: 350 patients (mean age 76.5, 56.6% female) were included in the older group and 150 in the control group (mean age 47.3, 55.3% female). Most patients presented with musculoskeletal or skin complaints (older cohort: 28.6% extremity pain/injury, 10% rash, 8.9% laceration, versus control 30% extremity pain/injury, 14.7% rash, 14.0% laceration) and were triaged to the ambulatory care area (88.6% elderly, 99.3% control). Older patients were significantly more likely than younger controls to be admitted on index visit (5.0% vs 0.3% admit rate, p=0.016). They had a trend towards increased re-presentation rates within 14 days (13.7% vs 8.7% control, p=0.11) and were more likely to be admitted on re-presentation (4.0% vs 0.7%, p=0.045). In sub-group analysis, very elderly patients (85 years and up, n=79) were more likely to be admitted (8.9%, p=0.003). Conclusion: Patients 65 years of age and older who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients 85 years and up are the primary drivers of this higher admit rate. This study characterizes “low acuity” elders presenting to ED and indicates these patients are high risk for re-presentation and admission within 14 days.

Introduction: Altered mental status (AMS) and cognitive impairment are common problems in elderly patients presenting to the emergency department (ED). The primary objective of this study was to test the diagnostic accuracy of the Ottawa 3DY (O3DY) screening tool for the detection of AMS in the ED. Methods: This was a prospective cohort study conducted at an inner city, academic ED with an annual census of 85,000 visits. Study investigators and trained research assistants screened and approached a convenience sample of patients for informed written consent. Patients completed the O3DY, Short Blessed Test (SBT) and Mini-Mental Status Exam (MMSE). Descriptive statistics using counts, medians, means and interquartile ranges (IQR) were calculated. Sensitivity and specificity of the O3DY compared to the MMSE were calculated in STATA (version 11.2). Results: We screened 163 patients for inclusion, 150 were eligible to participate, and 116 patients were enrolled in the final study. The median age of participants was 81 (IQR 77-85), 44.8% were female, and the most common pre-existing comorbidity was hypertension. The median ED LOS at the time of O3DY completion was 1:40 (IQR 1:34-1:46). Characteristics of patients eligible, yet who declined to participate, were similar to the study population. The sensitivity of the O3DY for AMS was 71.4% (95%CI 47.8-95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were moderate. Conclusion: In a cohort of geriatric patients presenting to an inner-city, academic ED the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of AMS.

Introduction: Cycling as a form of active transportation is popular in many urban communities. However, little is known about the prevalence and circumstances of cycling injuries, particularly injuries resulting from single bicycle crashes which are not recorded in road trauma surveillance systems based on police crash reports. This study aimed to examine the profile and circumstances of cycling injuries seen in an urban emergency department (ED). Methods: This was a cross-sectional historical chart review study. All injured patients attending our ED are electronically flagged according to mechanism of injury. We reviewed the medical charts of all ED visits in 2015 that were flagged as “Cyclist Injury” or “Fall” to identify all cyclists who were injured while travelling on public roads (including sidewalks). Off road injuries were excluded. Results: In 2015, a total of 6450 ED presentations were flagged as cyclist injury (n=694) or fall (n=5756), and 667 cycling injuries met our inclusion criteria. Of these, 73 (11%) were admitted to hospital. The most common mechanisms of injury were fall from bicycle (51%), crash into stationary object (16%), and collisions with moving motor vehicles (25%). Potential contributing factors included alcohol or drug impairment (11%), road hazards (9%), avoidance manoeuvre (5%) and dooring (3%), although the cause of the crash was generally poorly documented in the medical charts. The most common injured body regions were upper extremity (55%) followed by head and neck (34%). Most injuries were abrasions/lacerations and fractures. Conclusion: Two thirds of cyclist injuries in this series were caused by single bicycle incidents, events not captured in official road trauma statistics which are based on police crash reports. The large majority of injured cyclists were treated and released from the ED. In most cases, the cause of the crash was poorly documented. This data highlights the limitations of using police crash reports or hospital admission records for road trauma surveillance and the significant knowledge gap in our understanding of causative factors leading to cycling injuries.

Introduction: Recruitment and retention of healthcare staff are difficult in rural communities. Poor quality of work life (QWL) may be an underling factor as rural healthcare professionals are often isolated and work with limited resources. However, QWL data on rural emergency (ED) staff is limited. We assessed QWL among nurses and physicians as part of an ongoing study on ED care in Québec. Methods: We selected EDs offering 24/7 medical coverage, with hospitalization beds, in rural or small towns (Stats Canada definition). Of Québec’s 26 rural EDs, 23 (88%) agreed to participate. The online Quality of Work Life Systemic Inventory (QWLSI, with 1 item per 34 “life domains”), was sent to all non-locum ED nurses and physicians (about 500 potential participants). The QWLSI is used for comparing QWL scores to those of a large international database. We present overall and subscale QWL scores as percentiles (PCTL) of scores in the large database, and comparisons of nurses’ and physicians’ scores (t test). Results: Thirty-three physicians and 84 nurses participated. Mean age was 39.8 years (SD=10.1): physicians=37 (7.7) and nurses=40.9 (10.7). Overall QWL scores for all were in the 32nd PCTL, i.e. low. Nurses were in the 28th PCTL and physicians in the 44nd (p>0.05). For both groups, QWL was below the 25th PCTL i.e. very low, for “sharing workload during absence of an employee”, “working equipment”, “flexibility of work schedule”, “impact of working hours on health”, “possibility of being absent for familial reasons”, “relations with employees”. The groups differed (p<0.05) on only two subscales: remuneration and career path. For remuneration, scores were similar on fringe benefits (nurses 22nd PCTL, physicians 32nd) and income security (nurses 72nd, physicians 74th), but differed on income level (nurses 74th, physicians 93rd). The groups differed on all 3 career path items: advancement possibilities (nurses 53th, physicians 91st), possibilities for transfer (nurses 51nd, physicians 84th) and continuing education (nurses 18th, physicians 49th). Conclusion: Overall QWL among rural ED staff is poor. Groups had similar QWL scores except on career path, with physicians perceiving better long-term prospects. Given difficulties in rural recruitment and retention, these findings suggest that QWL should be assessed in rural and urban EDs nationwide.

Introduction: When patients transition from long term care (LTC) to emergency departments (ED), communication among clinicians in different settings is often poor. We pilot tested a transfer form to facilitate communications of handover information among LTCs, emergency medical services (EMS), and EDs regarding LTC residents transitioning to and from the ED. We interpret implementation challenges in light of the “theoretical domains” implementation framework in order to produce lessons for future healthcare communication interventions. Methods: We provided setting specific training and a user guide to 13 participating sites, collected 90 forms to assess completion rates, and assessed perspectives on the form from 266 surveys of healthcare providers. Throughout the study, staff kept detailed notes on implementation of the form. We retrospectively categorized implementation challenges reported by survey respondents, and/or recorded in staff implementation notes, according to the theoretical domains framework. Results: The LTC patient transfer forms were used in 36.4% of transitions (90/247), and were completed most often by staff in the LTC (57/90, 63%). Survey results indicated that ED and EMS staff felt the information on the form was useful to them, although they rarely completed their sections of the form. Implementation challenges included low awareness/recognition of the form among healthcare providers, belief that the form distracted from patient care, lack of time for form completion, negative reinforcement for LTC staff (who saw little return for the time they invested in completing the form), and mistrust among clinicians who work in different settings. Conclusion: Future efforts to improve healthcare communications must be acceptable for all clinicians. Innovation should balance the workload required among sites/clinicians and the benefits that the intervention offers to sites/clinicians should be explicitly tracked and reported. For this intervention, more effort should be made to inform LTC sites that the transfer information they provide is useful for EMS and ED clinicians. Moreover, gaps in perspectives and lack of trust among clinicians who work in different settings must be recognized and addressed in any multi-site communication intervention.

Introduction: Within Alberta, 30% of patients presenting to emergency with minor traumatic brain injury (mTBI) will receive a CT scan before being sent home, regardless of whether it was clinically indicated. Choosing Wisely (CW) Canada recommends using validated clinical decision support to determine whether a CT scan is necessary for patients presenting with a mTBI. In order to provide patients with information on the risks and benefits of CT scans in mTBI and to encourage discussions between patients and their doctor, the Emergency StrategicClinical Network (ESCN) designed a patient focused information visualization on CT scans for head injuries. Methods: The ESCN, Physician Learning Program and CW Alberta partnered with the Mount Royal University Department of Information Design to develop a patient information visualization (infographic) intervention. Students spent a semester developing these infographics on Choosing Wisely recommendations, which were then presented to stakeholders. A student was then selected to develop a final design. Refinement of the design took place in consultation with clinical experts and tested in two patient focus groups. The final design was evaluated against the International Patient Decision Aid Standards checklist. The infographic was posted in 2 local emergency department waiting rooms. A survey was administered to any patients in the waiting room when volunteers were available. The survey was designed to evaluate whether the tool influenced patient beliefs about the risks and benefits of CT scans, and their willingness to engage in a discussion with their doctor. Results: In a 26 day period, 90 patients consented and completed the survey. Before reading the infographic, 33% of patients thought that after a head injury a CT was always a good idea and 63% thought it was sometimes a good idea. 82% and 91% of patients stated the poster helped them understand the indications and risks of CT imaging for mTBI. After viewing the poster, only 15% of patients felt that a CT was always a good idea after a mTBI. Conclusion: The mTBI patient infographic significantly changed patient perceptions regarding the need for CT scans in the setting of mTBI. This study demonstrates that targeted patient education materials can help support CW recommendations.

Introduction: Appropriate pain management relies on the use of valid, reliable and age-appropriate tools that are validated in the setting in which they are intended to be used. The aim of the study was to assess the psychometric properties of pain scales commonly used in children presenting to the pediatric emergency department (PED) with an acute musculoskeletal injury. Methods: Convergent validity was assessed by determining the Spearman’s correlations and the agreement using the Bland-Altman method between the Visual Analogue Scale (VAS), Faces Pain Scale-Revised (FPS-R) and Color Analogue Scale (CAS). Responsiveness to change was determined by performing the Wilcoxon signed-rank test between the pre-post analgesia mean scores. Reliability of the scales was estimated using relative (Spearman’s correlation, Intraclass Correlation Coefficient) and absolute indices (Coefficient of Reliability). Results: A total of 495 participants was included in the analyses. Mean age was 11.9 ±2.7 years and participants were mainly boys (55.3%). Correlation between each pair of scales was 0.79 (VAS/FPS-R), 0.92 (VAS/CAS) and 0.81 (CAS/FPS-R). Limits of agreement (80%CI) were -2.71 to 1.27 (VAS/FPS-R), -1.13 to 1.15 (VAS/CAS) and -1.45 to 2.61 (CAS/FPS-R). Responsiveness to change was demonstrated by significant differences in mean pain scores, among the three scales, between pre- and post-medication administration (p<0.0001). ICC and CR estimates suggested acceptable reliability for the three scales at 0.79 and ±1.49 for VAS, 0.82 and ±1.35 for CAS, and 0.76 and ±1.84 for FPS-R. Conclusion: The scales demonstrated good psychometric properties with a large sample of children with acute pain in the PED. The VAS and CAS showed a stronger convergent validity, while FPS-R was not in agreement with the other scales. Clinically, VAS and CAS scales can be used interchangeably to assess pain intensity of children with acute pain.

Introduction: Computed tomographic pulmonary angiograms (CTPAs) are often ordered to evaluate pulmonary embolism (PE) in the emergency department (ED). However, these studies often yield alternative diagnoses and report incidental findings that lead to additional unnecessary investigations. Our objective was to assess the prevalence and significance of such findings and their implications in patient management. Methods: This is a retrospective cohort study of adults presenting to two tertiary care EDs in 2015, being evaluated with CTPA for PE. Data was extracted by two reviewers from electronic CT records with inter-rater reliability reported using kappa statistic. We measured prevalence of PE, incidental findings and alternative diagnoses with data reported as mean and standard deviation (SD). Univariate analyses were performed with t-test for continuous variables and Mantel-Haenszel test for categorical variables. A sample size of 770 was calculated based on an expected difference in prevalence between significant and non-significant incidental findings of 80% (α=5%, Power=90%). Results: A total of 1629 studies were included (mean 62 yrs, SD 16.7, 56.9% female, median CTAS score 2, 45.2% admitted). PE was found in 233 (14.3%) patients. 173 (10.6%) studies had a finding of an alternative diagnosis, the majority being pulmonary infiltrates (n=130, 75.1%). In patients who underwent both CTPA and chest x-ray (CXR), CXRs alone would have led to the same alternative diagnosis in 116 (77.1%) patients. A total of 223 (13.6%) patients had an incidental finding; the majority included pulmonary nodules (n=83, 37.2%) and adenopathy (n=26, 11.6%). Only 26 (17.1%) incidental findings were significant; most common included pulmonary nodules (n=6, 3.9%) and masses (n=7, 4.6%) that lead to newly identified and biopsied lung cancer diagnoses. Incidental findings led to an additional 301 follow-up CTs with a yield of significant result of 9.2% (n=48 CTs). Conclusion: Chest CTs ordered in the ED for clinical suspicion of PE is equally as likely to identify alternative diagnoses or incidental findings as PE. The majority of incidental findings are non-significant and result in an increased use of CT. CXRs should routinely be ordered prior to further investigation for PE with chest CT to reduce unnecessary testing and thus time and cost to the system.

Introduction: Multiple studies since the ‘90’s demonstrate that ED staff fail to identify delirium in up to 75% of older patients. Those patients who are discharged have a 3-fold increased mortality. Methods: We iteratively developed a 14-item interprofessional tool with 4 clinical vignettes to assess comfort, knowledge and ability to identify delirium among medical students, EM residents, staff MDs and RNs. We conducted a prospective observational study using modified Dillman survey methodology. Surveys were sent on paper to residents and nurses and online to medical students and staff MDs. Results: Our response rate was 68% (38/56) for residents, 80%(16/20) for RNs; but only 37%(13/35) for staff MDs and 13%(139/1036) for medical students. Comfort with identifying delirium increased with level of medical training; 38/139(27%) 1st-4th year medical students (MS1-MS4); 25/38(66%) 1st-5th year residents (R1-R5); and 12/13(92%) staff physicians reported being comfortable (χ2=34.7, df=2, p<0.001). MS1-MS2 were the least comfortable, with only 5/82(6%) reporting comfort, increasing to 33/57(58%) among MS3-MS4 (χ2=44.9, df=1, p<0.001). A greater proportion of R4-R5 who completed a geriatric emergency medicine (Geri-EM) curriculum reported comfort, 11/12(92%) compared to 14/26(54%) of R1-R3 (χ2=19.2, df=1, p<0.05). Only 5/16(31%) nurses reported being comfortable with identifying delirium. Ability to identify all 4 clinical vignettes correctly was higher among MS3-MS4 than MS1-MS2 (32/57(56%) vs. 30/82(37%), χ2=5.2, df=1, p<0.05). There was no difference between respondents from different levels of medical training (62/139(45%) MS1-MS4, 21/38(55%) R1-R5 and 6/13(46%) staff MDs, χ2=1.4, df=2 p=0.52). There was no effect of Geri-EM completion on perfect vignette scores (6/12(50%) R4-R5 vs. 15/26(58%) R1-R3, χ2=0.20, df=1, p=0.66). There was a trend towards a lower proportion of nurses who identified all 4 clinical vignettes correctly compared to physicians (4/16(25%) vs. 27/51(53%), χ2=3.82, df=1, p=0.051). Conclusion: Our tool may be useful for assessing comfort and knowledge of delirium among ED physicians and nurses. Completion of the Geri-EM curriculum was associated with increased comfort with detecting delirium but not knowledge. Future studies should assess current ED delirium comfort and knowledge at different levels of training; between professions and examine differences nationwide.

Introduction: The CJEM Social Media Team was created in 2014 to assist the journal with the dissemination of its research online. It consists of two Social Media Editors (Junior and Senior) and a team of volunteer medical students and residents to assist their work. Collaborative promotional agreements were developed to promote CJEM articles on the Skeptics’ Guide to Emergency Medicine (SGEM) podcast through the ‘Hot off the Press’ (HOP) series and the CanadiEM blog through an infographic series. Methods:CJEM papers were selected for promotion by the Team based on their perceived interest to the online community of emergency physicians. Altmetric scores, which are a measure of online dissemination derived from a weighted algorithm of social media metrics, were collated for articles promoted using the SGEM HOP or CanadiEM blogs. A control group was created using the articles with the top two Altmetric scores in each CJEM issue in 2015 and 2016. Erratum, Letters, and articles written by the social media editors were excluded from the control groups. The success of the social media promotion was quantified through the measurement of Altmetric scores as of January 1, 2017. Unpaired two-tailed t-tests with unequal variance were used to test for significant differences. Results: 106 and 82 eligible articles were published in 2015 and 2016, respectively. Four articles in 2015 and two articles in 2016 were excluded from the control groups because they were written by the social media editors. SGEM HOP podcasts promoted one article in 2015 and five articles in 2016. CanadiEM infographics promoted three articles in 2015 and eight articles in 2016. No articles were promoted in both series. The average Altmetric score was higher for SGEM HOP (61.0) than CanadiEM Infographics (31.5, p<0.04), 2015 controls (15.8, p<0.01), and 2016 controls (13.6, p<0.01). The average Altmetric score for CanadiEM Infographics was higher than 2015 controls (p<0.04) and 2016 controls (p<0.02). There was no significant difference between the control groups. Conclusion: The results suggest that collaborating with established social media websites to promote CJEM articles using podcasts and infographics increases their social media dissemination. Given the nonrandomized design of these results, causative conclusions cannot be drawn. A randomized study of the impact of social media promotion on readership is underway.

Introduction: Syncope accounts for 1-3% of Emergency Department (ED) visits. Previous studies have reported overuse of computed tomography (CT) of the head among syncope patients. Professional organizations including Choosing Wisely have recommended against its use in the absence of high-risk features. However, a review of CT head use among syncope patients and its diagnostic yield has not been previously reported. Methods: We conducted a systematic review using EMBASE, Medline, and Cochrane databases from inception to August 2016. We included studies involving adult syncope patients that reported CT head use and its diagnostic yield during acute management by a two-step process: first title/abstract review and then full-text review of selected articles. We excluded case reports, narrative reviews and those involving children. We collected the proportion of patients who had CT head performed, and its diagnostic yield. Outcomes included identification of acute intracranial conditions (hemorrhage, mass or infarct) that require further management. Two reviewers independently abstracted the data and discrepancies were resolved by consensus. We calculated inter-observer reliability for inclusion in the systematic review using kappa values. We performed meta-analysis for diagnostic yield of the CT head. Results: Fifteen studies with 2,802 syncope patients in four sub-groups (proportion of patients among whom CT head was performed and its yield in ED and inpatient settings; studies that reported only the yield among those with CT head performed; and the use and yield among syncope patients ≥65 years old) were included. The inter-observer agreement for inclusion of final articles for meta-analysis was κ=0.925 [95% CI: 0.861-0.990]. Seven ED studies (n=1,261) reported 55.7% patients (95% CI: 32.1-78.0%) had head CT performed with a yield of 4.0% (95% CI: 2.7-5.6%); 5 studies with 1138 hospitalized patients reported that 38.6% (95% CI: 20.4-58.6%) had head CT with a yield of 1.1% (95% CI: 0.4-2.2%). The yield among studies that report only outcomes for CT head was 2.3% and the yield among patients’ ≥65 years was 7.7%. Conclusion: Our review found that a very high proportion of syncope patients had CT head performed during acute management with a very low diagnostic yield. The yield is higher among patients ≥65 years old. A robust tool to identify patients who require a CT head will reduce unnecessary testing.

Introduction: Oral sweet solutions have been accepted as effective pain reducing agents for neonates. However studies in the Emergency Department (ED) setting have conflicting results. The objective is to compare the efficacy of an oral sucrose solution versus placebo in reducing pain in children 1 to 3 months of age during nasopharyngeal aspiration (NPA) in the ED. Methods: A randomized, double-blinded, placebo controlled clinical trial was conducted in a pediatric university-affiliated hospital ED. Participants from 1 to 3 months of age requiring NPA were recruited and randomly allocated to receive 2 mls of an 88% sucrose solution (SUC) or 2 mls of a placebo solution (PLA) orally, 2 mins before NPA. The primary outcome was the mean difference in pain scores at 1 min post NPA as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale. Secondary outcomes were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time, heart rate and adverse events. Results: 72 participants were recruited and completed the study, 37 (group SUC) and 35 (group PLA) respectively. Both groups had similar demographic and clinical characteristics and baseline FLACC and NIPS pain scores (all p=value >0.4). The mean difference in FLACC scores compared to baseline was 3.3 (2.5-4.1) (SUC) vs. 3.2 (2.3-4.1) (PLA) (p=.94) at 1 min and -1.2 (-1.7 to 0.7) (SUC) vs. -0.8 (-1.5 to -0.1) (PLA) (p=.66) at 3 mins after NPA. For the NIPS scores, it was 2.3 (1.6-3.0) (SUC) vs. 2.5 (1.8-3.2) (PLA) (p=.86) at 1 min and -1.2 (-1.6 to -0.8) (SUC) vs. -0.8 (-1.3 to 0.2) (PLA) (p=.59) 3 mins after NPA. There was no difference in the mean crying time, 114 (98-130) secs (SUC) vs. 109 (92-126) secs (PLA) (p=.81). No significant difference was found in participants’ heart rate at 1 min 174 (154-194) BPM (SUC) vs. 179 (160-198) BPM (PLA) (p=.32) and at 3 mins 165 (143-187) BPM (SUC) vs. 164 (142-186) BPM (PLA) (p=.86) after NPA. Three patients had vomiting during the procedure (2 PLA and 1 SUC), and one had an episode of chocking (PLA). Conclusion: In infants 1 to 3 months of age undergoing nasopharyngeal aspiration in the ED, administration of an oral sweet solution did not statistically decrease pain scores as measured by the FLACC and NIPS scales. Participants’ heart rate and crying time were not significantly decreased when sucrose was provided.

Introduction: Headache is a common emergency department (ED) presentation. Benign (i.e., non-pathological) headaches are particularly common, including exacerbations of chronic migraine, tension, and cluster headache. Several studies have reported concerns over the frequent use of advanced imaging, specifically computed tomography (CT), in the ED management of benign or primary headache presentations. This systematic review examined the proportion of adult ED benign headache presentations who receive a CT(head). Methods: Eight bibliographic databases and the grey literature were searched. All studies reporting the proportion of benign headache patients receiving a CT(head) in the ED were eligible for inclusion. Studies which included a secondary headache population of 15% of their total study population or less where eligible for inclusion. Two reviewers independently assessed study inclusion and completed quality assessment and data extraction. Weighted medians were calculated for the primary and secondary outcomes, as appropriate. Results: The search returned 2,444 unique citations, of which 20 met the inclusion criteria (21 patient groups were analyzed). The majority of the studies were descriptive in nature and conducted in North America. The reported proportion of benign headache patients receiving a CT(head) varied considerably (range: 2.06-67.21%); with a weighted median of 30.0% (interquartile range: 30.0, 30.0). Studies published in 2000 or later (18/21 groups) were found to have a higher weighted median percentage compared to those published pre-2000 (p=0.016). Neither the country of origin nor the proportion of patients with secondary headache included within the study population had a significant effect on CT utilization. Of the three studies which reported the discharge diagnosis of all patients, sub-arachnoid hemorrhage was discovered in 2/241 (0.83%) of CT scans. Conclusion: Considerable variation in CT utilization for benign headache ED presentations exists and estimates indicate that more than a quarter of patients receive a CT(head). Overall, these CT scans rarely identify significant pathology, suggesting imaging may be safely reduced. Further research is required to identify interventions which can safely and effectively reduce unnecessary imaging among headache presentations.

Introduction: With the increased accessibility of computed tomography (CT), use in the emergency department has increased. Increased use has lead to a reduction in missed diagnoses but also an increase in radiation burden and the increased likelihood of incidental findings. In this study, we sought to characterize the use of abdominal CTs at an academic tertiary center in order to quantify the rate and clinical significance incidental findings. Methods: This was a retrospective chart review of radiological database of all abdominal CT ordered by the emergency department from January 1st to March 21st 2015. Incidental findings requiring follow up were defined by the American college of radiology guidelines. Clinically significant incidental findings were defined as those that resulted in a finding of malignancy or comparably serious disease. Abdominal CTs were excluded if they were ordered together with CT thorax. The data was abstracted by one trained reviewer using a standardized data collection sheet and 10% of the data was verified by a second reviewer. Inter-rater reliability reported by Kappa statistic. Data were reported as mean and standard deviation. A sample size of 770 was calculated based on an expected difference in prevalence between significant and non-significant incidental findings of 80% (α=5%, Power=90%). Results: A total of 1882 imaging studies were included (56.3% female, age 59.4 years (16.3), CTAS 3 (1.3). The most common presenting complaints: abdominal pain (980, 52.1%), flank pain (196, 10.4%) and nausea/vomiting (111, 6%). Indications included rule out (r/o) obstructing renal stones/colic (329; 17.5%), r/o diverticulitis/colitis (307; 16.4%) and abdominal pain not yet differentiated (283; 15.1%). The most common final diagnoses as a result of CT were renal stone/colic (212, 11.3%), colitis/diverticulitis (191, 10.2%), and bowel obstruction (111, 6%).Incidental findings recommending further imaging occurred in 93 (4.9%). Of these, 43 were completed, and 15 resulted in clinically significant findings: cancer of the colon (2), lung (2), bladder (2), metastatic cancer (2), adnexa (4), endometrium (1), lymphoma (1), and venous thrombus (1). Conclusion: Incidental findings are far less common (5%) then previously reported (as high as 30%) and rarely clinically significant.

Introduction: Syncope is a common emergency department (ED) presentation and constitutes 1% of all ED visits, approximately 160,000 visits annually across Canada. Lack of standardized syncope care has economic and cost implications. Currently, emergency medical services (EMS) is over utilized, variations in ED management exist and a substantial proportion (46.5%) are hospitalized for cardiac monitoring. Our previous studies have proposed ways to reduce health care utilization through development of EMS clinical decision tool, ED risk scores and remote cardiac monitoring. We sought to: 1) Estimate costs associated with syncope care in the pre-hospital, ED and inpatient settings; and 2) Determine potential cost savings if the proposed alternate strategies were adopted. Methods: A prospective cohort study was conducted in five Canadian EDs from 2010-2014. We enrolled adult (≥16 years) syncope patients and excluded those with prolonged loss of consciousness, mental status changes, seizure, significant trauma, or alcohol/illicit drug abuse. Demographics, medical history, mode of arrival, EMS time points, reasons for hospitalization, ED and inpatient length of stay, final ED diagnosis and any serious adverse event within 30 days of index visit were collected. Descriptive and inferential statistics were used. Results: Out of 4,064 patients enrolled, 67.3% were transported to the ED by EMS and the average cost per event was $262.78 (range at study sites: $156.43-$553.03). The average cost per ED visit was $267.98 (range: $174.66-$374.95). 12.9% of the patients were admitted and the average of cost per admission was $9,886.15 (range: $9,715.23-$10,277.98). Syncope is associated with an estimated total annual cost of $257 million. In Canada, we estimate that diverting low-risk patients will save $5 million in the pre-hospital setting and $15 million in the ED annually, and implementing a remote cardiac monitoring strategy will save $50 million annually. Conclusion: It is estimated that the proposed strategies will save $70 million annually. This is likely an underestimation as cost savings due to reduction in investigations related to diversion of ED patients, reduction in ED length of stay and hospitalization are unaccounted. Adoption of similar strategies will likely lead to significantly higher cost savings in countries with higher resource utilization for syncope management.