Introduction: Emergency department (ED) buprenorphine/naloxone inductions for opioid use disorder are an effective and safe way to initiate addictions care in the ED. Kelowna General Hospital's ED buprenorphine/naloxone (KEDSS) program was implemented in September 2018 in order to respond to a community need for accessible and evidence-based addictions care. The objective of our program evaluation study was to examine the implementation of the first five months of the KEDSS program through evaluating patient characteristics and service outcomes. Methods: The KEDSS treatment pathway consists of a standardized protocol (pre-printed order set) to facilitate buprenorphine/naloxone induction and stabilization in the acute care setting (ED and inpatient wards) at Kelowna General Hospital, a community academic hospital. All patients referred to the outpatient addictions clinic via the order set during September 2018-January 2019 (the first 5 months) were included in the study population. A retrospective descriptive chart review was completed. Outcome measures included population characteristics (sociodemographic information, clinical characteristics) and service outcomes (number of patients initiated, patient follow-up). Descriptive statistics and bivariate analyses using t-tests or Pearson's χ2 statistic, as appropriate, were conducted to compare the ED-initiated group with the inpatient-initiated group. Results: During the first five months of the KEDSS program, a total of 35 patients (26% female, mean age 36.6 years, 54% homeless) were started on the treatment pathway, 16 (46%) in the ED. Compared to the inpatient-initiated group, the ED-initiated group were less likely to have psychiatric comorbidities (ED 1.0 vs. inpatient 1.5, p = 0.002), require methadone or sustained-release oral morphine (ED 13% vs. inpatient 37%, p = 0.048), and have attended follow-up (ED 56% vs. inpatient 84%, p = 0.004). Conclusion: This study provides a preliminary look at a new opioid agonist therapy (OAT) treatment pathway (KEDSS) at Kelowna General Hospital, and provides insight into the population that is accessing the program. We found that the majority of patients who are started on buprenorphine/naloxone in the ED are seen in follow-up at the addictions clinic. Future work will examine ongoing follow-up and OAT adherence rates in the study population to quantify the program's impact on improving access to addictions treatment within this community hospital setting.

Introduction: Mild Traumatic Brain Injury (mTBI) is a common problem: each year in Canada, its incidence is estimated at 500-600 cases per 100 000. Between 10 and 56% of mTBI patients develop persistent post-concussion symptoms (PPCS) that can last for more than 90 days. It is therefore important for clinicians to identify patients who are at risk of developing PPCS. We hypothesized that blood biomarkers drawn upon patient arrival to the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and the incidence of PPCS 90 days post mTBI. Methods: Patients were recruited in seven Canadian ED. Non-hospitalized patients, aged ≥14 years old with a documented mTBI that occurred ≤24 hrs of ED consultation, with a GCS ≥13 at arrival were included. Sociodemographic and clinical data as well as blood samples were collected in the ED. A standardized telephone questionnaire was administered at 90 days post ED visit. The following biomarkers were analyzed using enzyme-linked immunosorbent assay (ELISA): S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial fibrillary acidic protein (GFAP). The primary outcome measure was the presence of persistent symptoms at 90 days after mTBI, as assessed using the Rivermead Post-Concussion symptoms Questionnaire (RPQ). A ROC curve was constructed for each biomarker. Results: 1276 patients were included in the study. The median age for this cohort was 39 (IQR 23-57) years old, 61% were male and 15% suffered PPCS. The median values (IQR) for patients with PPCS compared to those without were: 43 pg/mL (26-67) versus 42 pg/mL (24-70) for S100B protein, 50 pg/mL (50-223) versus 50 pg/mL (50-199) for NSE, 2929 pg/mL (1733-4744) versus 3180 pg/mL (1835-4761) for c-Tau and 1644 pg/mL (650-3215) versus 1894 pg/mL (700-3498) for GFAP. For each of these biomarkers, Areas Under the Curve (AUC) were 0.495, 0.495, 0.51 and 0.54, respectively. Conclusion: Among mTBI patients, S100B protein, NSE, c-Tau or GFAP during the first 24 hours after trauma do not seem to be able to predict PPCS. Future research testing of other biomarkers is needed in order to determine their usefulness in predicting PPCS when combined with relevant clinical data.

Introduction: Compared to other areas in Alberta Health Services (AHS), internal data show that emergency departments (EDs) and urgent care centres (UCCs) experience a high rate of workforce violence. As such, reducing violence in AHS EDs and UCCs is a key priority. This project explored staff's lived experience with patient violence with the goal of better understanding its impact, and what strategies and resources could be put in place. Methods: To obtain a representative sample, we recruited staff from EDs and a UCC (n = 6) situated in urban and rural settings across Alberta. As the interviews had the potential to be upsetting, we conducted in-person interviews in a private space. Interviews were conducted with over 60 staff members including RNs, LPNs, unit clerks, physicians, and protective services. Data collection and analysis occurred simultaneously and iteratively until saturation was reached. The analysis involved data reduction, category development, and synthesis. Key phrases and statements were first highlighted. Preliminary labels were then assigned to the data and data was then organized into meaningful clusters. Finally, we identified common themes of participants’ lived experience. Triangulation of sources, independent and team analysis, and frequent debriefing sessions were used to enhance the trustworthiness of the data. Results: Participants frequently noted the worry they carry with them when coming into work, but also said there was a high threshold of acceptance dominating ED culture. A recurring feature of this experience was the limited resources (e.g., no peace officers, scope of security staff) available to staff to respond when patients behave violently or are threatening. Education like non-violent crisis intervention training, although helpful, was insufficient to make staff feel safe. Participants voiced the need for more protective services, the addition of physical barriers like locking doors and glass partitions, more investment in addictions and mental health services (e.g., increased access to psychiatrists or addictions counsellors), and a greater shared understanding of AHS’ zero tolerance policy. Conclusion: ED and UCC staff describe being regularly exposed to violence from patients and visitors. Many of these incidents go unreported and unresolved, leaving the workforce feeling worried and unsupported. Beyond education, the ED and UCC workforce need additional resources to support them in feeling safe coming to work.

Introduction: Most emergency departments (ED) in Canada have a population of high frequency users that present to the ED on a regular basis. These patients are well described in the literature and typically defined by a frequency of 8-10 visits/year. In Thunder Bay, Ontario we have a significant population of patients that present more often that we have termed “super-users”. These patients often are typically from a vulnerable population with multiple co-morbidities and a high mortality rate. Although their risk for poor health outcomes is well recognized, both the chronicity and complexity of their symptoms often contributes to diagnostic dilemmas. The decision to order a computed tomography (CT) scan can be a difficult balance between ruling out life threatening diagnoses and exposing the patient to excessive radiation. Our objective was to describe how often these super-users of the ED received a CT scan and what types of imaging were completed. Methods: The Thunder Bay Regional Health Sciences Centre is a geographically isolated hospital in Northwestern Ontario with the next closest hospital based CT scanner greater than 300 km away. Based on previous literature and our preliminary scoping of the super-user group, we have identified a minimum of 25 visits as the threshold. A retrospective chart review was conducted for the year 2017 using our electronic medical record. Patient demographic data was collected along with the type and number of CT scans into a standardized collection tool. Results: Our preliminary results showed that our total population of super-users was 75 patients with an average of 32 visits to the ED per year. A total of 76% of the patients had a CT scan completed at least once. On average these patients have a CT during 10% of their visits with head CT comprising 50% of the imaging and abdominal/pelvis imaging comprising another 45%. For 20% of these super-users, they had CTs on 20% of their visits. From this population, only 10% of the patients had surgery in 2017 while 7% of visits required admission to hospital. The most common diagnoses for these patient visits relate to mental health/addictions, gastrointestinal complaints and infection. Conclusion: This study has shown that a significant number of our super-user population are receiving multiple CTs. Our next step is collect data on individual radiation doses and calculate exposure risks. We hope to inform policy and decision-makers who are developing programs to treat the underlying cause of their high resource use.

Introduction: The Maximizing Aging Using Volunteer Engagement in the ED (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program and the activities performed with older patients by its volunteers. Methods: The MAUVE + ED program was implemented in the ED (annual census 65,000) of a large academic tertiary hospital in Toronto, Ontario. Volunteers were trained to identify and approach older patients and others at greater risk for adverse outcomes, including poor patient experience, in the ED and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. Results: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median (IQR) time a MAUVE volunteer spent with a patient was 10 (5, 20) minutes, with a range of 1 to 130 minutes. The median (IQR) number of patients seen per shift was 7 (6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). Conclusion: Preliminary data suggest the MAUVE + ED volunteers were able to enrich the experience of older adults and their families/carers in the ED.

Innovation Concept: Global health fieldwork is valuable for Canadian residents, but is often trainee-organized, short-term, unsupervised, and lacking in preparation and debriefing. In contrast, we have developed a Certificate Program which will be offered to University of Toronto (UofT) emergency medicine (EM) trainees in their final year of residency. This 6-month Program will complement the Transition to Practice stage for residents interested in becoming leaders in GHEM. Methods: We completed a multi-phase needs assessment to inform the structure and content of a GHEM Certificate Program. Phase 1 consisted of 9 interviews with Program Directors (PDs), Assistant PDs, and past fellows from existing GH fellowships in Canada and USA to understand program structure, curriculum, fieldwork and funding. In Phase 2 we interviewed 4 PDs and fellows from UofT fellowship programs to understand local administrative structures. In Phase 3 we collected feedback from 5 UofT residents and 7 faculty with experience in global health to assess interest in a local GHEM Program. All interview data was reviewed and best practices and lessons learned from key stakeholders were summarized into a proposed outline for a 6-month GHEM Certificate Program. Curriculum, Tool, or Material: The Program will comprise of 1) 3 months of preparatory work in Toronto followed by 2) 3 months of fieldwork in Addis Ababa, Ethiopia. Fieldwork will coincide with activities under the Toronto-Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM). The GHEM trainee's work will support TAAAC-EM activities. Preparatory months will include training in specific competencies (POCUS, teaching, tropical medicine, QI) and meetings between the trainee and a UofT mentor to design an academic project. During fieldwork, the trainee will do EM teaching (75% of time) and complete their academic project (25% of time). A UofT supervisor will accompany, orient and supervise the trainee for their first 2 weeks in Addis. Throughout fieldwork, the trainee will be required to debrief with their UofT mentor weekly for academic and clinical mentoring. One AAU faculty member will be identified as a local supervisor and will participate in all evaluations of the trainee during fieldwork. Conclusion: This Program will launch with a call for applications in July 2021, expecting the first trainee to complete the Program in 2022-23. We anticipate that this Program will increase the number of Canadian EM trainees committed to global health projects and partnerships throughout their career.

Introduction: The FAST exam – Focused Assessment with Sonography in Trauma - is a rapid test using ultrasound to identify sonographic evidence of hemorrhage within the abdomen. In the prehospital setting, the information from a FAST examination can help triage patients, direct patients to the most appropriate facilities, assist with management strategies and potentially expedite time to definitive intervention. Few studies examine the accuracy of paramedic-only-performed FAST examinations. However, despite the potential benefits to the Canadian prehospital system, a potential barrier to implementation is the tremendous financial and operational burden if paramedics require prolonged ultrasound training courses. In this study, we conducted a double-blinded observational study comparing the accuracy of paramedic-performed FAST versus physician-performed tests on a sonographic Phantom, after a one-hour didactic training session. Methods: The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model. The mannequin utilized in this study was a realistic model of a human torso where fluid could be injected into the abdomen to create a realistic ultrasound image of abdominal free fluid. Participants were required to scan the mannequin twice, once with 300 mL of fluid instilled and once with the abdomen free of fluid. Participants were blinded to the status of hemoperitoneum. The primary outcome of the study was accuracy rate of FAST examination by paramedics compared to emergency room physicians. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. Total scan time was reported using means, standard deviations and 95% CIs and was compared between groups using standard t-test. Results: Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were ultrasound-naive whereas the emergency physicians had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups 85.6% and 87.5% (Δ1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. Total scan time differed between groups but did not reach statistical significance. Paramedics took longer to complete the FAST examination with a mean (SD) time to complete the two scans of 10.35 (3.43) minutes compared to 7.34 (2.74) minutes for physicians, (Δ3.01 minutes 95%CI -0.97 to 7.00, p = 0.13). Conclusion: This study determined that critical care paramedics were able use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of ultrasound in prehospital programs to determine the most appropriate transport destination and aid in the triage of trauma patients while limiting the financial and logistical burden of ultrasound training.

Introduction: Atrial Fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). AF increases the risk of ischemic stroke which can be mitigated by anticoagulant prescription. National guidelines advise that emergency physicians initiate anticoagulation when AF is first diagnosed. We aimed to evaluate the 90-day incidence of stroke and major bleeding among emergency patients discharged home with a new diagnosis of AF. Methods: This was a health records review of patients diagnosed with AF in two EDs. We included patients ≥ age 18, with a new diagnosis of AF who were discharged from the ED, between 1st May 2014 and 1st May 2017. Using a structure review we collected data on CHADS65 and CHADS2 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), ischemic gut, ischemic limb or other systemic embolism within 90 days of the index ED presentation. We extracted data on major bleeding events within 90 days, defined by the International Society of Thrombosis and Haemostasis criteria. All data were extracted in duplicate for validation. Results: We identified 399 patients fulfilling the inclusion criteria, median age 68 (IQR 57-79), 213 (53%) male. 11 patients were already prescribed an anticoagulant for another indication and 19 had a contraindication to prescription of a DOAC. 48/299 (16%) CHADS65 positive patients were initiated on an anticoagulant, 3 of whom had a contra-indication to initiation of anticoagulation in the ED (1 dual antiplatelet therapy, 2 liver cirrhosis). 1/100 CHADS65 negative patients was initiated on anticoagulation. The median CHADS2 score was 1 (IQR 0-2). Among the 49 patients initiated on anticoagulation, 3 patients had a stroke/TIA within 90 days, 6.1% (95% CI; 2.1-16.5%). There were no bleeding events 0.0% (95% CI; 0.0-7.3%). Among the 350 patients who were not initiated on anticoagulation in the ED, 4 patients had a stroke/TIA 1.1% (95% CI; 1.1-2.9%) within 90 days and 2 patients had a major bleeding event. Conclusion: Prescription of anticoagulation for new diagnoses of AF was under-utilized in these EDs. The 90-day stroke/TIA rate was high, even among those given an anticoagulant prescription in the ED. No patient had an anticoagulant-associated bleeding event.

Introduction: Trauma resuscitations are plagued with high stress and require time sensitive and intensive interventions. It is a landscape that is a perfect hot bed for clinical errors and adverse events for patients. We sought to describe the adverse events and errors that occur during trauma resuscitation and any associated outcomes. Methods: Medline was searched for a combination of key terms involving trauma resuscitation, adverse events and errors from January 2000 to May 2019. Studies that described adverse events or errors in initial adult trauma resuscitations were included. Two reviewers analyzed papers for inclusion and exclusion criteria with a third reviewer for any discrepancies. Descriptions of errors, adverse events and associated outcomes were collated and presented. Results: A total of 3,462 papers were identified by our search strategy. 18 papers met our inclusion and exclusion criteria and were selected for full review. Adverse events and errors reported in trauma resuscitation included missed injuries, aspiration, failed airway, and deviation from protocol. Rates of adverse events and errors were reported where applicable. Mortality outcomes or length of stay were not directly correlated to adverse events or errors experienced in the trauma resuscitation. Conclusion: Our study highlights the predominance of adverse events and errors experienced during initial trauma resuscitation. We described a multitude of adverse events and errors and their rates but further study is needed to determine outcome differences for patients and possibility for quality improvement.

Background: Curbing unnecessary laboratory testing represents a significant opportunity for cost reduction in the Canadian health care system. A Choosing Wisely report cited a 31% decline in the number of tests ordered in a Canadian emergency department (ED) after implementation of recommendations. The international normalized ratio (INR) remains frequently ordered in emergency departments without an appropriate indication. Aim Statement: We aimed to reduce the number of INR tests completed in the St. Joseph's Healthcare Hamilton Emergency Department by 50% by April 30, 2019. Measures & Design: We conducted the study in an urban, academic ED employing the Epic electronic health record (EHR). We tailored interventions according to the Hierarchy of Effectiveness to address root causes revealed by analysis of our baseline ordering behaviour. Interventions included provider education around evidence-based ordering indications and removal of the INR from our “chest pain” bloodwork panel. Our outcome measure was the weekly number of INR tests completed per ED visit. Process measures included the proportion of INR tests ordered for inappropriate indications on monthly audits of 20 charts where an INR was completed. Balancing measures included average ED length of stay for patients receiving INR testing. Evaluation/Results: We collected outcome, process, and balancing measures through the EHR and analyzed this data using statistical process control charts. Over the nine-month study period, we decreased weekly INR tests from 248.4 to 115.0, a reduction of 56% which met criteria for special cause variation. This amounts to a cost savings of $43,008 per year. ED length of stay for patients receiving INR testing did not change significantly. Discussion/Impact: Our interventions were successful in realising our 50% target reduction in INR tests without an increase in ED length of stay from repeat venipuncture. This result is in keeping with similar efforts in other Canadian EDs. Our interventions could likely be spread to other settings where an INR is included as part of a “chest pain” panel. This may represent a substantial cost reduction opportunity on a national scale. Further work is needed in order to assess long term sustainability, which can be supported by employing high effectiveness mechanisms such as automation of optimal behaviour.

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.

Introduction: All emergency departments (EDs) across Canada can identify a group of high frequency users, which are typically defined in the literature as eight to ten visits per year. Although frequent users of the ED are well-studied in the literature, there is little published in terms of identifying the “super-user” group who present to the ED much more often than 10 visits per year. Faced with multiple co-morbidities and a high mortality rate, the ED is often the most appropriate environment to manage this population. In order to inform future initiatives to improve health outcomes, we aimed to identify the specific characteristics of this super-user group. Methods: A retrospective chart review was conducted using the electronic medical record from the Thunder Bay Regional Health Sciences Centre to identify patients who had at least 25 visits in the year 2017. A total of 75 patients presented to the ED greater than 25 times in 2017. The following data was then collected on each individual patient: demographic characteristics including age, gender, address, access to a primary care provider. In addition, we collected date, time, diagnoses at each visit, admission rate and surgical interventions. Results: Our preliminary results reveal this population presents to the ED on average 32 times per year. The population is 53% male. Most have a private address and half have a primary care provider for all 2017 with one quarter having a primary care provider for part of the year. The percentage of visits for infections was 30%, mental health and addictions presentations comprised 28% of the visits, with gastrointestinal and cardiac visits comprising a total 22% of the visits. Approximately 7% of visits required admission to hospital, and the average length of stay was 5 days. Conclusion: Super-users of the ED are a unique population that are typically well connected with primary care and have a very low admission and surgical rate. The most common reasons for visit are infections and mental health and addictions. The next steps include collecting mortality data. This data should be used to inform ED and community initiatives aimed at improved health outcomes for this population.

Introduction: Choosing Wisely Canada has reported rates of unnecessary head computed tomography (CT) scans for low-risk mild traumatic brain injury (mTBI) patients in Ontario and Alberta ranging from 14% to 46%. Local data for Quebec is currently not available. We sought to estimate the overuse of CT scans among adults with mTBI in the emergency department (ED) of a single level II trauma center in Quebec. Methods: We performed a retrospective chart review of adults who visited the ED of Hôtel-Dieu de Lévis from 04/01/2016 to 03/31/2017. Using an administrative database (Med-GPS, Montreal), we randomly sampled ED patients aged over 18 that had an initial Glasgow Coma Scale score of 13 to 15 and had suffered from a mTBI in the last 24 hours. We excluded patients with an unclear history of trauma, a bleeding disorder/anticoagulation, a history of seizure, any acute focal neurological deficit, a return visit for reassessment of the same injury, unstable vital signs, or a pregnancy. Data was extracted by two reviewers who analyzed separate charts. They used the Canadian CT Head Rule (CCHR) to determine relevance of CT scans. Overuse was determined if a patient without any high or medium risk CCHR criteria underwent a scan. A third reviewer verified a 10% random sample of the data extraction for each primary reviewer and inter-rater reliability was assessed using the kappa statistic. Results: From the 942 eligible mTBI patients, we randomly selected 418 patient charts to review, of which 217 met all inclusion and exclusion criteria (56% were men and the mean age was 48 years old (SD = 21)). Among included patients, 101 were determined as low risk. The overuse proportion was 26% (26/101), 95% CI [18-35]. Two CT scans were assessed as abnormal, but none revealed life-threatening injuries and only one was considered clinically significant with a subdural hematoma of 9 mm. Inter-rater reliability was substantial to perfect (kappa = 0.6 and 1.0) for each primary reviewer. Conclusion: We identified head CT scan overuse in this ED. This will support local quality improvement initiatives to reduce unnecessary head CT scans for adults with mTBI.

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

Introduction: Incidental findings (IFs) are findings discovered in the course of healthcare (e.g., blood tests, genetic tests, imaging) that are unrelated to the primary purpose for which a test was sought. Some IFs constitute new knowledge that have implications for patient autonomy and welfare. IFs found in emergency departments (EDs) are difficult to manage, with one study reporting that of 392 patients with IFs, 122 had no follow-up and 242 had no electronic record of the finding. Methods: A critical interpretive literature review was conducted to explore current practices regarding identification, disclosure, and management of IFs in EDs, and to identify ethical challenges that require research focus and policy reform. The search strategy included ‘incidental findings’ AND ‘emergency’ and derivatives, retrieving 12,021 studies from databases including PubMed, Scopus, and Web of Science, as well as handsearching and reference list searching. Following screening, 97 studies were included. Data was extracted, analyzed using descriptive statistics, and then critically interpreted to capture key ideas. Results: Of 97 included articles, 75 have relevant empirical data. Of the 75, most literature (89%) presented the frequency of IFs in EDs, with an average frequency of 34%. Most (84%) did not report on patient disclosure rates or follow-up rates. When reported, patient notification rates are as low as 2.6% with an average of 15% over 12 studies. Empirical studies included in the review do not address ethical principles or patient preferences on disclosure. The literature reveals suggestions to manage IFs in EDs, including implementation of automatic feedback or alert mechanisms, clarification of responsibilities within treating teams, protocols in radiology departments, and improvements to patient documentation. Test results by letter are noted as insufficient because patients are unable to ask questions. Authors suggest further research on optimal follow-up recommendations to alleviate patient and physician distress. Further results will be presented, critically interpreted, and discussed, with attention to ethical implications and challenges. Conclusion: The literature on IFs in EDs focuses too narrowly on frequency, with ad hoc suggestions for practice, research, and policy changes to improve the ethical management of IFs. Numerous factors, including crucial knowledge gaps, contribute to inadequate management of IFs arising in EDs. Research and ethics informed policy guidance is needed.

Introduction: Naloxone is recommended for reversing opioid-associated respiratory depression. There is wide variability in emergency department (ED) practice patterns regarding naloxone use, dosing, and observation time post-administration. This study describes the naloxone practice patterns of ED physicians managing suspected opioid overdose patients. Methods: A retrospective chart review was conducted of adult patients (≥ 18 years) presenting to an academic tertiary care centre (consisting of two EDs with an annual census 150,000 visits) in 2017 with suspected opioid overdose who were administered naloxone in the ED. Patients were identified electronically and the following information was abstracted from patient charts: demographics, naloxone dosage and infusion initiation, disposition data, indications for naloxone administration, response to therapy, and adverse effects. Variability in initial and total dose was examined. Initial dose was also compared in those with cardiorespiratory compromise (CPR given, respiratory rate < 8, or desaturation below 89%) using independent samples median tests. Data was analyzed using standard descriptive statistics. Results: 113 patients met inclusion criteria. Indications for naloxone administration were: level of consciousness (50.5%), respiratory depression (4.0%), miosis (1.0%), a combination of factors (19.8%), or undocumented (24.8%). Median initial dose was 0.40 mg (IQR: 0.20-0.40 mg). Median total naloxone administered in the ED was 0.48 mg (IQR: 0.35-1.2 mg). The initial dose resulted in a response in 43.1% of patients, with 36.0% of responding patients later experiencing subsequent respiratory depression. 31% of patients received a naloxone infusion. Initial dose in patients with cardiopulmonary compromise was significantly different only comparing patients who received CPR versus those who did not (median 0.40 mg; IQR: 0.20-0.80 mg; P = 0.019). Four patients experienced emesis following naloxone. Median length of ED stay was 7.0 hours (IQR: 4.0-9.5 hours), and median hospital length of stay was 3.0 days (IQR: 1.0-5.0 days). Median ED observation time prior to discharge was 4.0 hours (IQR: 2.0-8.0 hours). Ultimate disposition home, to the ward, or to the intensive care unit was 47.1%, 42.2%, and 9.8% respectively (1.0% deceased). Conclusion: The dose and usage of naloxone by ED physicians in this study is variable. Further prospective studies are needed to determine the effective naloxone dosing strategy.

Introduction: Delays in definitive management of critically ill patients are known to drive poor clinical outcomes. A scarcely studied time period in interfacility transfer is the time between initial patient presentation and the decision to transfer. This study seeks to identify patient, environmental and institutional characteristics associated with delays in decision to transfer critically ill patients by air ambulance to a tertiary care centre. Methods: Patients >18 years old who underwent emergent air ambulance interfacility transport to a tertiary care centre were included. Patient records were located in a provincial air ambulance database. The primary exposure variable was time from patient presentation to initial call to facilitate transfer. Patient, environmental and institutional characteristics were identified using stepwise variable selection at a significance of 0.1. These characteristics were then explored using quantile regression to identify significant factors associated with delay in transport initiation. Results: A total of 11231 patients were included in the analysis. There were 5009 females (44.60%) and 6222 males (55.4%). The median age of patients was 57. The median time to initiate the transfer was 3.05 hours. The variables identified with stepwise selection were gender, category of illness, heart rate, systolic blood pressure, Glasgow coma scale, vasopressor usage, blood product usage, time of day, and type of sending site. The following factors were significantly (p < 0.05) associated with an increase in time to initiate transfer compared to the reference category at the 90th centile of time: cardiac illness (+1.45h), gastrointestinal illness (+3.27h), respiratory illness (+4.90h), sepsis (+3.03h), vasopressors (+2.31h), and an evening hour of transport (+3.67h). The following factors were significantly (p < 0.05) associated with a decrease in time to initiate transfer compared to the reference category at the 90th centile of time: neurologic illness (-1.45h), obstetrical illness (-1.56h), trauma (-3.14h), GCS <8 (-0.98h), blood transfusion (-1.47h), and sending site being a community hospital >100 beds (-2.26h), <100 beds (-4.71h), or nursing station (-10.02h). Conclusion: Time to initiate transfer represents a significant window in a patient's transport journey. In looking at the predictors of early or late initiation of transfers, these findings provide education and quality improvement opportunities in decreasing time to definitive care in critically ill populations.

Introduction: Diagnosing deep vein thrombosis (DVT) is of critical importance because of its associated morbidity and mortality. Diagnosing DVT can be challenging in the Emergency Department (ED) due to inconsistent adherence to, and utilization of the Wells rule. Both the age-adjusted and clinical probability adjusted D-dimer have been shown to decrease ultrasound (US) utilization rates. We aimed to compare the safety and efficacy of the Wells score with D-dimer to the age-adjusted and clinical probability-adjusted D-dimer in Canadian ED patients tested for DVT. Methods: This was a health records review of ED patients investigated for DVT at two EDs over a two-year period. Inclusion criteria were ED physician ordered duplex ultrasonography or D-dimer for investigation of lower limb DVT. Patients under the age of 18 were excluded. DVT was considered to be present during the ED visit if DVT was diagnosed on duplex ultrasonography and was treated for acute DVT, or if the patient was subsequently diagnosed with pulmonary embolism (PE) or DVT during the next 30 days. Trained researchers extracted anonymized data. The Wells D-dimer, age-adjusted D-dimer, and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of duplex ultrasonography imaging and the false negative rate was calculated for each rule. Results: Between April 1st 2013 and March 31st 2015, there were 1,198 patients tested for DVT. Of the low and moderate clinical pretest probability patients (Wells score ≤ 2), only 436 had a D-Dimer test and were eligible for our analysis. The average age of the patients was 59, 56% were female, and 4% had a malignancy. 207/436 patients (47.4%, 95%CI 42.8-52.2%) would have had US imaging for DVT if the age-adjusted D-dimer rule was used. 214/436 patients (49.1%, 95%CI 44.4-53.8%) would have had imaging for DVT if the clinical probability-adjusted D-dimer was used. If the Wells rule was used with the standard D-dimer cutoff of 500, 241/436 patients (55.2%, 95%CI 50.6-59.9%) would have had imaging for DVT. The false-negative rate for the Wells rule was 1.5% (95%CI 0.5-4.4%). The false-negative rate for the age-adjusted D-dimer rule was 1.3% (95%CI 0.4-3.8%). The false-negative rate for the clinical-probability adjusted D-Dimer was 1.8% (95%CI 0.7-4.5%). Conclusion: In comparison with the approach of the Wells score and D-dimer, both the age-adjusted and clinical probability-adjusted D-dimer diagnostic strategies could reduce the proportion of patients who require US imaging.

Introduction: There are few large-scale studies assessing the true risk of epinephrine use during anaphylaxis in adults. We aimed to assess the demographics, clinical characteristics, and secondary effects of epinephrine treatment and to determine factors associated with major and minor secondary effects associated with epinephrine use among adults with anaphylaxis. Methods: From May 2012 to February 2018, adults presenting to the Hôpital du Sacré-Coeur de Montréal (HSCM) emergency department (ED) with anaphylaxis were recruited prospectively as part of the Cross-Canada Anaphylaxis Registry (C-CARE). Missed cases were identified through a previously validated algorithm. Data were collected on demographics, clinical characteristics, and management of anaphylaxis using a structured chart review. Multivariate logistic regression models were compared to estimate factors associated with side effects of epinephrine administration. Results: Over a 6-year period, 402 adult patients presented to the ED at HSCM with anaphylaxis. The median age was 38 years (Interquartile Range [IQR]: 27, 52) and 40.4% were males. The main trigger for anaphylaxis was food (53.0%). A total of 286 patients (71.1%) received epinephrine treatment, of which 23.9% were treated in the pre-hospital setting, 47.0% received treatment in the ED, and 5.0% received epinephrine in both settings. Among patients treated with epinephrine, major secondary effects were rare (1.4% of patients), including new changes to electrocardiogram, arrhythmia, and neurological symptoms. Minor secondary effects due to epinephrine were reported in 50.0% of patients, mainly inappropriate sinus tachycardia (defined as a rate over 100 beats/minute in 30.1%). Major cardiovascular secondary effects were associated with regular use of beta-blockers (aOR 1.10 [95%CI, 1.02, 1.18]), regular use of ACE-inhibitors (aOR 1.16 [95%CI, 1.07, 1.27]), and receiving more than two doses of epinephrine (aOR 1.09 [95%CI, 1.00, 1.18]). The model was adjusted for age, history of ischemic heart disease, trigger of anaphylaxis, presence of asthma, sex, and reaction severity. Inappropriate sinus tachycardia was more likely in females (aOR 1.18 [95%CI, 1.04, 1.33]) and palpitations, tremors, and psychomotor agitation were more likely in females (aOR 1.09 [95%CI, 1.00, 1.19]) and among those receiving more than two doses of epinephrine (aOR 1.49 [95%CI, 1.14, 1.96]). The models were adjusted for age, regular use of medications, history of ischemic heart disease, triggers of anaphylaxis, presence of asthma, reaction severity, and IV administration of epinephrine. Conclusion: The low rate of occurrence of major secondary effects of epinephrine in the treatment of anaphylaxis in our study demonstrates the overall safety of epinephrine use.

Background: Over 35,000 Canadians lose their lives to cardiac arrest each year. CPR and automated external defibrillator (AED) use are modifiable factors. Survival rates drop by 7-10% each minute that defibrillation is delayed, and survival rates are less than 5% after 12 minutes of ventricular fibrillation which stresses the need for bystander AED use in out-of-hospital arrests. Niagara Region lacks a publicly accessible registry of AEDs. AED access is a major focus in King County, Washington which has higher survival rates and has all AEDs registered with Emergency Medical Services. Aim Statement: This project aims to log 100 or more AEDs within a year into a publicly accessible registry and to connect the registry information to medical trainees in the Niagara region and all employees of the Niagara Health System involved in patient care. Measures & Design: PulsePoint is an application used to register AEDs within the Niagara region. PulsePoint allows users to geotag AEDs while tracking data entries. Over 16 weeks, 4 PDSA cycles tested the effectiveness of logging methods for AEDs including opportunistic logging, daily emailed reminders, and contacting organizations with high likelihood of having an AED. Information about the project and registry was shared with residents and medical students in Niagara. A second phase of cycles involves relaying information to Niagara Health system employees and the medical community. A final cycle will target a broader group of local organizations with intermediate probability of having AEDs. Primary outcome measures include the numbers of regional AEDs logged and members reached by knowledge sharing cycles. Evaluation/Results: PulsePoint was found to be an effective, free, publicly accessible resource to log AEDs within the Niagara region. The initial round of 4 PDSA cycles added a total of 56 new AEDs within the region, which were logged into PulsePoint app and the Excel spreadsheet. Through the fourth PDSA cycle, 136 businesses were contacted and made aware of the project and the AED application. In addition,138 health-related colleagues and medical students were contacted to raise awareness. PDSA cycles five through eight are currently ongoing or in the planning stages. Discussion/Impact: Raising awareness among emergency services and sharing information about the registry to local CPR training providers will be paramount. Creating awareness of PulsePoint and installing AEDs in locations that currently lack such devices could ultimately improve cardiac arrest survival rates within Niagara Region.