Introduction: Non-trauma centers (NTC) and community hospitals commonly deliver medical care during the “golden hour” of trauma, which has significant implications on the health outcomes of patients. The Niagara Health System (NHS) and its 3 community NTC hospitals provide trauma care to over 100 patients annually during this critical period. NTCs lack standardized resources commonly found in trauma centers. Checklists and bundles have been effective in streamlining process to ensure health care providers provide the right care, at the right time and address critical points during patient care. A trauma care bundle was designed and implemented in the NHS as a means to improve trauma care and patient outcomes. Methods: A quality improvement (QI) approach was used to design, implement and evaluate a trauma care bundle at one of the NHS’s community hospitals. These interventions were adapted and modified for community trauma care purposes. We piloted the trauma care bundle using rapid cycle improvements, known as Plan-Do-Study-Act (PDSA) cycles. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015-December 2015. A safety attitudes questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Results: Improvements to the bundle and its implementation from 4 PDSA cycles resulted in increased utilization. This continuous monitoring of the bundle and ongoing, conscious efforts to improve the intervention were used to spread and scale across all 3 sites of the NHS. 30% of patients received the trauma care bundle during phase 1 of the pilot from July 1- October 31, 2015. We are presently analyzing preliminary data to understand how the trauma care bundle impacts health outcomes and process and will present a comparative analysis between patient groups. Conclusion: Trauma care bundles may foster safer and more efficient patient care in community hospitals where the golden hour of trauma often occurs. This community trauma care bundle shows promising results for streamlining the care process to ensure patients receive appropriate care during the golden hour. Spread and scale of this bundle across other community hospitals will likely yield similar improvements in patient care.

Introduction: Acute Aortic Dissection (AAD) is life threatening, requiring early diagnosis. Although previous literature suggest interarm BP differential is an independent predictor of AAD, up to 20% of a healthy population can have a significant differential. Our objectives were to assess the rate of bilateral BP measurement in acute non-traumatic truncal pain patients, and the association of BP differential with non-traumatic AAD. Methods: This is a historical matched case control study: participants were adults >18 years old presenting to two tertiary care EDs with a triage diagnosis of truncal (i.e. chest, abdominal, flank, back) pain. Cases were selected based on an ED or in-hospital diagnosis of non-traumatic AAD confirmed by CT or Echo. Controls were from a single calendar year matched in a 1:1.5 ratio by sex and age within 5 years. ED and referral consult BP measurements were used. Exclusion criteria: clear diagnosis on basic investigation (i.e. UTI, pneumonia, pneumothorax, acute fracture) or pain >14 days/no pain. Sample size of 126 cases and 183 controls was calculated based on 20% exposure in controls (80% power and alpha of 5%), to detect an OR >2. P-values were calculated using chi square analysis. Results: A total of 294 (119 cases, 175 controls) patients were included (mean 66+/-14.5yrs, 59.5% male). Cases (199 potential: 119 included; 80 excluded). Controls (8239 potential: 305 reviewed; 175 included; 130 excluded). Bilateral BP was measured in 70.6% of cases (n=84, mean difference=15.5mmHg) versus 31.3% of controls (n=55, mean difference=10.9mmHg). Among included controls, most common diagnoses were: Unspecified Chest (36.0%) or Abdominal (9.7%) Pain, ACS (12.6%), Muscular Back Pain (5.1%), and Renal Colic (4.0%). BP differential >10mmHg was found in 58.8% of cases and 40.7% of controls (P=0.10). A BP differential >20mmHg was found in 31.3% of cases and 22.2% of controls (P=0.37). BP differential >20mmHg did not significantly increase the odds of AAD (OR 2.0 (95%CI 0.82-4.90), p<0.129). Conclusion: Interarm BP differential is not routinely measured in ED patients with acute non-traumatic truncal pain, and there is no significant difference in the presence or magnitude of differentials in patients with or without AAD. Therefore, physicians should not rely on BP differentials to aid in their diagnosis or exclusion of AAD.

Introduction: Adverse drug events (ADEs), harmful and unintended consequences of medications, account for 1.7M emergency department (ED) visits in Canada each year. Up to 30% are due to unintentional re-prescribing of culprit drugs, partly due to lack of accessible, succinct, and comprehensible ADE information at the time of prescribing. Through a systematic review and workshops with physicians and pharmacists, we designed new ADE documentation fields. Our objective was to pilot-test the fields to anticipate and address problems prior to their integration into an electronic medical record (EMR). Methods: We seek to introduce structured ADE documentation into an EMR and PharmaNet, BC’s medication-dispensing database, to generate patient-level alerts when attempts to re-prescribe culprit drugs are made. We conducted this qualitative study in the EDs and on the wards of two BC hospitals. The ADE fields collect information about the culprit drug, its effect on the patient, treatment and outcome. We recruited a convenience sample of pharmacists, and distributed paper forms with the ADE fields to them before data collection shifts. We recorded how pharmacists evaluated patients for ADEs and completed the forms. We collected completed forms, and conducted semi-structured interviews for feedback. We analyzed data for common themes using inductive reasoning and constant comparison methods. Results: We observed 6 pharmacists documenting 24 ADEs. The field design was perceived as simple, clear, with sufficient detail to capture ADE information. Users identified fields to be omitted (e.g., excess details of culprit drug), modified (e.g., reporting options), or needing clarification (e.g., treatment details). Users were uncertain about what to report when the differential diagnosis included an ADE, but diagnostic uncertainty remained. Thus, ADE fields should enable communication about suspected events and potential alternative diagnoses. Pharmacists required follow-up in some cases to complete their determination (e.g., C. difficile toxin assay), emphasizing the need to be able to modify an ADE report. Conclusion: Paper-based pilot testing uncovered barriers to ADE documentation, and allowed us to plan for modifications and required linkages between electronic systems. In order to be functional, electronic ADE documentation must be dynamic, representing a departure from previous reporting platforms.

Introduction / Innovation Concept: During Emergency Department (ED) resuscitation of critically ill patients, effective teamwork and communication among various healthcare professionals is essential to ensure favorable patient outcomes and to minimize threats to patient safety. However, numerous individual and system factors create barriers to effective team functioning. Simulation center- based training has been used to improve Crisis Resource Management skills among physician and nursing trainees, but in-situ simulation is a relatively new concept in adult Emergency Medicine in North America. Methods: To enhance patient care and team effectiveness, an ED nursing and physician group was created to develop and implement a novel interprofessional in-situ simulation program in two Canadian, academic tertiary-care emergency departments. Departmental approval and financial support was obtained and sessions commenced in January 2015. Curriculum, Tool, or Material: Monthly high-fidelity simulation sessions are held in the ED resuscitation rooms at both campuses of our hospital. Each session is facilitated and debriefed by simulation-trained Emergency Medicine faculty and senior residents, a nurse educator and a research assistant. Technical support is provided by our simulation center staff. Participants are recruited from the physicians, residents, nurses, respiratory therapists and other support staff working in the ED. To minimize the impact on patient care, two additional nurses are scheduled to cover nursing assignments on “sim days”. Simulations are limited to fifteen minutes, followed by a twenty minute debriefing. Conclusion: We have successfully developed and implemented an interprofessional in-situ simulation program in our ED. Participant feedback has been overwhelmingly positive. Lack of financial support, reluctance of staff to participate, and overwhelmed resources are some of the challenges to running a program like this in a busy ED environment. However, there are clear benefits: empowering team members, culture change, identification of latent safety threats, and a perception of improved teamwork and communication.

Introduction: Recent years have brought an epidemic of opioid abuse to Canada. At present, in Ontario, Naloxone may not be administered by any paramedic without the direct online medical approval of a Base Hospital Physician (BHP). The objective of this study was to review the use of Naloxone by Emergency Medical Service (EMS) personnel, under the existing Advanced Life Support Patient Care Standards (ALS-PCS) medical directive for opioid toxicity, for safety and potential complications that may occur with removal of the mandatory patch point. Methods: This study was a retrospective ambulance call report review of consecutive Naloxone requests placed to a BHP of the Regional Paramedic Program of Eastern Ontario (RPPEO) between Oct 1st, 2013 and Oct 31st, 2015. The RPPEO consists of 10 prehospital services, both urban and rural jurisdictions, and has a mix of advance care and primary care paramedics. All ambulance call reports are electronically stored at the secured RPPEO data warehouse. Data was extracted using a standardized data collection tool. All ambulance call reports were reviewed by 2 independent authors (VC, NC). Compliance with the existing medical directive for opioid toxicity was determined. We calculated the frequency of denied Naloxone requests and the rationale for each patch refusal was recorded. We also categorized all adverse events associated with Naloxone administration. Results: From 244 patches, 215 patients were administered Naloxone. Only 7.8% (19/215) of requests for Naloxone were refused; 78.9% (15/19) did not meet existing inclusion criteria for Naloxone administration in the ALS-PCS medical directive for opioid toxicity because the patient’s respiration rate was above 12/min. Of the 215 patients who were administered Naloxone, adverse events were extremely uncommon: 5 (2.3%) became violent or verbally abusive, 1 (0.5%) was transiently hypertensive and 4 (1.9%) vomited. Conclusion: Requests for Naloxone to a BHP are common and yet are seldom declined. The use of prehospital Naloxone is associated with few adverse events. These results demonstrate that it would be safe to remove online medical direction for Naloxone from the ALS-PCS medical directive for opioid toxicity if combined with updated paramedic education.

Introduction: Incapacitated patients who lack substitute decision-makers (SDM) are commonly encountered in the emergency department (ED). The number of these patients will rise dramatically as the Baby Boomers age. We can expect an influx of elderly patients who lack decisional capacity due to dementia and other illnesses, and who present without family. It is estimated that 3 to 4 percent of U.S. nursing home residents have no SDM or advance directives. Medical decision-making for this cohort poses an ethical challenge, particularly in the ED setting. Methods: A comprehensive review of the literature was conducted surrounding decision-making for incapacitated and unrepresented patients in the hospital setting. Articles were identified using MEDLINE (1946-October 2015) and Embase (1974-October 2015). The reference lists of relevant articles were hand searched. Articles describing decision-making processes that have been proposed, tested or applied in practice were chosen for full review. The aim of this review was to outline recognized medical decision-making processes for incapacitated and unrepresented patients, and to identify areas for future research. Results: The search yielded 20 articles addressing decision-making for incapacitated and unrepresented patients in the hospital setting. All of these articles focus on the intensive care unit and other hospital wards; no literature on the ED setting was found. Five types of formal consulting bodies exist to assist physicians in applying the best interest standard for this patient cohort: internal hospital ethics committees, external ethics committees, public guardians, court-appointed guardians, or judges. The majority of decisions for these patients, however, are made informally by a single physician or by a healthcare team, although it is well recognized that this approach lacks appropriate safeguards. There is no consensus surrounding the optimal approach to decision-making in these cases, and as such there is significant inconsistency in how medical decisions are made for these patients. Conclusion: There are several articles describing decision-making processes for incapacitated and unrepresented patients, none of which focus on the ED. These processes are not practical for use in the ED. Further inquiry is needed into the most ethical and respectful method of decision-making for this patient cohort in the ED.

Introduction: Patients who are homeless and/or using substances rely heavily on emergency departments (ED) for medical care, and present with complex medical and social needs. Negative physician attitudes towards this population undermine the therapeutic relationship, compromising the quality of medical care provided. The objective of this study was to determine the attitudes of emergency physicians towards homeless and substance-using patients. Methods: Using a Modified Total Design approach, we conducted a cross-sectional survey of emergency physicians at five different healthcare locations in Calgary, Alberta, Canada. Attitudes were assessed using two validated measures, the Health Care Providers Attitudes Towards the Homeless Inventory (HPATHI), and the Short Understanding of Substance Use Scale (SUSS). Surveys were self-administered by respondents between March and December 2013. Results: A total of 117 physicians completed the survey (response rate 48%). 28% of respondents resented the amount of time it takes to see homeless patients, and 32% believed caring for homeless patients was not financially viable; 57% felt overwhelmed by the complexity of problems that homeless people have. Physicians with extra training in addiction medicine or health care for the homeless had more positive attitudes than physicians with no extra training; physician attitudes worsened over time towards both populations. Conclusion: Physicians feel overwhelmed when caring for patients who are homeless and/or substance using and negative attitudes worsened over time. Extra training in addiction medicine or healthcare for the homeless is associated with more positive attitudes. Possible strategies to improve attitudes should include a multifaceted approach addressing individual physician knowledge deficits, as well as expanded access to resources in the ED and community, designed to deal with the complex needs of these populations.

Introduction / Innovation Concept: The Shock Trauma Air Rescue Society (STARS®) is a charitable, non-profit organization that is dedicated to providing a safe, rapid, highly specialized emergency medical transport system for the critically ill and injured. The STARS® Mobile Education Unit (MEU) is comprised of a high fidelity simulation suite that mimics a hospital emergency room, installed in a specially equipped motorhome (SEM) that can wirelessly operate a high fidelity human mannequin. The MEU provides an excellent opportunity to combine continuing medical education for resuscitation and MCI management. At present, no formal MCI education process exists in Saskatchewan. Curriculum, Tool, or Material: The Saskatchewan STARS® MEU delivers a phased MCI education initiative to rural and regional centers within the province. The educational initiative is sub-divided into three stages: 1. pre-exercise knowledge translation using a flipped classroom approach, 2. on-site tabletop exercise (TTX) and, 3. high-fidelity simulation session with a review of MCI management principles . Sites perform a Hazard Vulnerability Analysis (HVA) following stage 2 and the highest identified site-specific risks are utilized during the development of the simulated scenarios for stage 3. During stage 2, participants also complete a pre and post-exercise survey. The survey evaluates the educational component, the tabletop exercise component and the perceived pre and post tabletop exercise competencies for the management of MCI. In the pilot project, two regional sites completed the tabletop exercise. The pre-exercise survey evaluated perceived MCI and disaster preparedness for the region. Only 8% and 25% of participants at each site respectively, reported that their disaster plan had been trialed in tabletop, full exercise or real activation within the past three years. Participants strongly agreed that the tabletop exercise was a valuable experience (86% and 88% respectively). More robust data will become available as the initiative transitions out of the pilot stage to formal operations. Conclusion: A formal MCI training program implemented through the STARS® MEU for rural Saskatchewan municipalities enables participants and their organizations to both review and enhance their current emergency management plans. This initiative will aim to establish a foundation for future collaboration at the provincial and national level for rural MCI training and preparedness.

Introduction: The D-dimer assay is a high sensitivity, low specificity test used to rule out pulmonary embolism (PE) in low risk ED patients. Patients with a positive D-dimer result will likely undergo CT imaging to confirm the diagnosis. Given the time, cost, and radiation exposure associated with CT, and the higher false-positive rate in older patients, an age-adjusted D-dimer threshold may be preferred. Our objective was to evaluate the sensitivity and specificity of an age-adjusted D-dimer and approximate the downstream effect on CT imaging utilization. Methods: This was a retrospective cohort study conducted using administrative data from Calgary emergency departments between July 2013 and January 2015. Eligible patients were individuals aged 50 and older who were undergoing PE workup including D-dimer testing. Outcomes were ascertained using CT imaging reports and by searching the regional administrative database for subsequent diagnosis of PE within 30 days of the index visit. These data were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value of the D-dimer test using the standard threshold (500 ng/mL) and an age-adjusted threshold (10 ng/mL x patient age as an integer). From this, the potential reduction in CT imaging use and missed PE diagnoses were modeled. Results: Of 6669 patients aged 50 or older who had D-dimer testing for possible PE, 1504 (22.6%) underwent a CT scan, and 217 (14.4% of CT) received a discharge diagnosis of pulmonary embolism, which was confirmed on chart review. When test results were re-interpreted using an age-adjusted threshold, D-dimer specificity increased from 63.9% to 75.4%, while sensitivity decreased from 96.5% to 89.9%. This translates to 888 new true negatives, representing CT scans potentially avoided (a 59% reduction in CT utilization), but with 18 new missed PE diagnoses. Conclusion: The age-adjusted threshold may reduce use of CT imaging among older patients suspected of PE, but at the cost of more missed PE diagnoses.

Introduction: Emergency medicine (EM) is characterized by one time patient encounters where the end diagnosis is often unknown. Seeking patient outcome feedback, (POF) which is defined as following a patient’s clinical course once they leave your care, is crucial as it can highlight a discord between an intended verses actual result, thus spurring clinical change. This study seeks to determine whether EM staff and residents currently seek POF, the types of patients followed and the barriers faced. Methods: An online survey was administered to all EM staff and residents (CCFP-EM and FRCP) working at a tertiary academic hospital to determine their current practices and attitudes towards POF. Results: A total of 72 responses were received, of which 41 were residents and 31 were staff, for an overall response rate of 95%. If feedback was sought, the most commonly used tools were looking up imaging results (52%) and talking to EM colleagues (42%). The patients most frequently followed were those with a poor outcome during their ED admission, sick patients with unclear final diagnosis or unplanned returns within 48 hours (55%, 58%, 34% respectively). However, up to 30% of respondents never or rarely sought out POF even in these situations (16%, 19% and 30% respectively). Patients least commonly followed were those where the diagnosis was more certain. Respondents identified many barriers, primarily being time (83%), not being notified about bouncebacks (79%) and remembering which patients to follow (70%). Barriers were amplified for residents as they had a harder time accessing or automatically receiving POF. The most useful tools not currently available, would be being able to easily create electronic tracking lists, being automatically sent discrepant imaging reports and automatic notification of patients who return to the ED within 48hrs. Also, automatic follow up information on patients who experienced a negative outcome or on sick patients with unclear diagnosis is desired. Conclusion: POF is a useful and crucial practice for clinical care, but is currently not often performed. The most commonly used tools are those that are easiest to access, and POF was mainly performed on patients with either negative results or unclear diagnoses. Thus, identifying the types of patients deemed most relevant for receiving POF and addressing the major barriers faced by clinicians can help improve the frequency with which POF is sought, potentially improving patient care.

Introduction: Remote ischemic conditioning (RIC) is a non-invasive therapeutic strategy that uses brief cycles of inflation and deflation of a blood pressure cuff to reduce ischemia-reperfusion injury during acute ST-elevation myocardial infarction (STEMI). The primary objective of this systematic review was to determine if RIC initiated prior to catheterization increases myocardial salvage index, defined as the proportion of area at risk of the left ventricle salvaged by treatment following emergent percutaneous coronary intervention (PCI) for STEMI. Secondary outcomes included infarct size and major adverse cardiovascular events. Methods: Electronic searches of PubMed, Ovid MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were conducted and reference lists were hand-searched. Randomized controlled trials comparing PCI with and without RIC for patients with STEMI published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as risk ratios (RR) with 95% confidence intervals (CIs). Results: Nine RCTs were included with a combined total of 999 patients (RIC+PCI = 534, PCI = 465). The myocardial salvage index was higher in the RIC+PCI group at 3 and 30 days; mean difference 0.09 (95% CI: 0.04, 0.15) and 0.12 (95% CI: 0.03, 0.21), respectively. Infarct size was reduced in the RIC+PCI group at 3 and 30 days; mean difference -3.82 (95% CI: -8.15, 0.51) and -4.00 (95% CI: -7.07, -0.93), respectively. There was no statistical difference with respect to death and re-infarction, however there was a reduction in heart failure with RIC+PCI at 6 months; RR: 0.43 (95% CI: 0.19, 0.99). Conclusion: RIC is emerging as a promising adjunctive treatment to PCI for the prevention of reperfusion injury in STEMI patients. Ongoing, multicenter clinical trials will help elucidate the effect of RIC on clinical outcomes such a hospitalization, heart failure and mortality.

Introduction: A hot, painful, swollen joint is a common presentation to the emergency department. Of the potential etiologies, septic arthritis (SA) is the most devastating. Prompt diagnosis and treatment are essential to improve outcomes. Both culture proven and clinically suspected SA are thought to have the same prognosis, with similar morbidity and mortality estimates. No clinical exam or serum lab finding has the sensitivity or specificity to diagnose or exclude SA. Instead, diagnosis relies mainly on joint aspiration and synovial fluid analysis. A synovial white blood cell count (sWBC) greater than 50,000 cells/microliter is suggestive of SA and organisms seen on gram stain or growing in culture effectively makes the diagnosis. However, culture and gram stain are positive in only 67% and 50% of cases respectively. The objective of this study was to analyze the accuracy of synovial fluid analysis in our local practice environment. Methods: All those encounters with diagnoses related to SA at four adult emergency departments in Calgary between 2013-2014 were reviewed. Hospital records were analyzed for synovial analysis, antibiotic usage and surgical procedures. Results: Of 286 encounters, 87 were determined to satisfy the definition for SA in that culture was positive, gram stain was positive or clinical findings lead to treatment with antibiotics and/or surgical intervention. Gram stain was positive in 22% of cases with cultures positive in 51% of patients. sWBC were less than 50000 in 55% of cases and less than 25000 in 24% of cases. Of 88 gram stains performed, 28% were negative but had positive culture. All positive gram stains were associated with positive cultures. Conclusion: Culture, gram stain and sWBC of patients diagnosed with SA in Calgary show differences compared with the published literature. In Calgary, the majority of SA diagnoses were made clinically. The sWBC is central to making the diagnosis. Interestingly, 55% of patients diagnosed with SA had a count less than 50,000. It remains unclear what features of history, physical exam, imaging and lab analysis lead to the diagnosis of SA in these cases. Future studies will focus on these outliers to see if a more appropriate diagnostic algorithm would be useful in Calgary. Collaboration between infectious disease specialists, orthopedics, and emergency departments guided by local data is needed to ensure accurate and timely diagnosis.

Introduction: Chest pain and symptoms of acute coronary syndrome are responsible for a large proportion of ED visits and acute hospitalizations. However, only about 15% of patients presenting to the ED with high-risk symptoms do, in fact, have an acute coronary syndrome. The objective of this study is to derive a 2-hour high-sensitivity Troponin T (hsTnT) testing algorithm with outcome based-cutoffs to rapidly rule out acute myocardial infarction (AMI) in a large proportion of ED chest pain patients. Methods: Patients included consecutive ED patients with a chief complaint of cardiac chest pain who had an hsTnT assay performed at ED arrival and 2 hours after ED arrival. Administrative databases were queried to identify troponin results and major adverse cardiac outcomes (MACE) including death, MI, and revascularization. Test characteristics of iterative combinations of initial troponin level and absolute change in troponin level were quantified in order to identify the testing algorithm that identified the greatest proportion of patients eligible for early discharge while maintaining a target sensitivity of 98.5% for the primary outcome of 7-day AMI. Results: 755 eligible patients had hsTnT assays performed at ED arrival and at 2 hours. 91 patients (12.1%) had a 7-day AMI while 108 (14.0%) had 7-day MACE. An initial hsTnT level of less than 14 ng/L, in combination with a 2-hour absolute change of less than 10ng/L had a sensitivity of 98.9% (95% CI 94.0,99.8) and an NPV of 99.8% (95% CI 98.7, 100.0) for 7-day AMI. This identified 58.5% of all patients as being suitable for early discharge. Sensitivity and NPV for 7-day MACE were 90.0% (95% CI 83.3, 94.2) and 97.3% (95% CI 95.3,98.4) respectively. Sex-specific differences in test characteristics were not clinically important. Rule-in hsTnT cutoffs were also evaluated, with specificities ranging from 85-95%, although cutoffs with higher specificity had less ability to rapidly rule-in AMI, leaving more patients with indeterminate results after 2 hours. Conclusion: A hsTnT algorithm can safely and accurately rule out AMI in 58.5% of ED chest pain patients within 2 hours of ED arrival. The lower sensitivity of this algorithm for MACE compared to AMI speaks to the importance of clinical assessment and ECG findings in identifying patients at risk for acute coronary syndromes.

Introduction: Paramedics are sometimes called for crisis management and relief of symptoms or for patients receiving palliative care. To address the mismatch between the system protocols and resources, and patient’s goals of care, a new protocol, new medications, and an 8-hour training program Learning Essentials Approach to Palliative Care (LEAP) were implemented in our provincial EMS system. Methods: Prior to attending their training session paramedics received an invitation to complete an online survey regarding their comfort, confidence, and attitudes toward delivering palliative care. Comfort and confidence questions were scored on a 4-point Likert scale, while attitudes toward specific aspects of care were scored on a 7-point Likert scale. Descriptive statistics were calculated. Identifiers will permit linkage of these responses to a repeat survey post-implementation. Results: 188 (58%) paramedics completed the survey of the 325 who opened the link. 134 (68%) were male with a mean age of 38.5 years. 95 (50%) were primary care paramedics. The average experience as a paramedic was 12.7 years, with an estimated mean number of palliative calls per year of 9.6 each. On a 4 point scale, most (156, 83%) were comfortable with providing care to someone with palliative goals, and 130 (69.1%) were comfortable providing care without transport. Only 82 (43.6%) were confident they had the tools to deliver this care, and 76 (40.4%) were confident they could do so without transport to hospital. On a 7 point scale, paramedics disagreed with the statement “caring for dying persons is not a worthwhile experience for me”, median 7 (IQR 5-7). Paramedics also disagreed with the statement “Dying persons make me feel uneasy”, median 5 (IQR 4-6). Conclusion: Prior to the implementation of the new protocol, medications, and training, most paramedics were comfortable with the concept of providing care with palliative goals and felt that caring for dying persons is a worthwhile experience, but they were not confident that they have the tools and resources to do so. This suggests paramedics would be open to system improvements to meet an unmet healthcare need for crisis management of patients with palliative goals of care.

Introduction: Variations of patient volumes in the ED according to days of the week and month of the year are well-established. Anecdotally, ED volumes follow ‘waves’ that correlate with previous days. Time-series models have traditionally been used in econometrics to develop financial models, but have been adapted in other fields, such as health informatics. This study uses a time-series approach to assess whether these impressions are valid. Methods: The daily volume of patients presenting to four emergency departments (ED) at the Nova Scotia Health Authority from Jan 2010 to May 2015 were analyzed to assess for the effect of previous volumes on future volumes. Parameters were selected using the auto-correlation (ACF) and partial auto-correlation functions (PACF) for a Seasonal Auto-regressive Integrated Moving Average (SARIMA) model. The Box-Jenkins statistic was assessed for model suitability. To assess for accuracy, a forecast of the model was evaluated with a year of volumes set aside for testing. Results: The EDs saw an average of 365.1 patients per day, with a minimum of 188 patients and a maximum of 479. The increasing trend in volumes consistent with the increasing number of ED presentations nation-wide was detrended using linear regression. There was a significant correlation in ACF with the previous day (ρ1 = 0.297). A seasonal, periodic trend was seen weekly. Significant correlations occurred annually (ρ365 = 0.279) and at 29 days (ρ29 = 0.339), consistent with the lunar cycle. A seasonal model was postulated incorporating an auto-regressive (AR) coefficient, and a moving average (MA) coefficient for the previous day’s volume. An AR and MA seasonal coefficient were each incorporated using the weekly period. When using the model on the test data, the model predicted 4 more patient presentations on average than the true value, with 90% of the values within 37 presentations of the true volume. The Box-Jenkins statistic was non-significant, indicating no problems with model specification. Conclusion: The volume of patients presenting to an ED system is correlated with that of the previous day. A weekly seasonal variation was confirmed. Auto-correlations also occur annually and possibly associated with the lunar cycle. Previous ED volumes may be useful in forecasting patient volumes. The time-series approach may discover further ways to predict ED volumes.

Introduction: The International Student Association of Emergency Medicine (ISAEM) is a non-profit organization composed of medical students and student groups who believe that everyone deserves high-quality emergency care. Our aim is to promote and foster the concept, philosophy, and art of Emergency Medicine (EM). More specifically, we seek to 1) create an international network of medical students interested in EM, 2) support EM Interest Groups (EMIGs) and medical students in accomplishing their goals, 3) call for the recognition of EM as an independent specialty in countries where it does not exist, 4) help medical students learn, practice, and advance EM in countries where it is already established, and 5) carry out international projects for the benefit of medical students interested in EM. Methods: ISAEM tries to accomplish its goals primarily by connecting interested medical students and EMIGs with each other, as well as with EM professionals and organizations around the world. Additionally, we support medical students and EMIGs financially, offer them extensive benefits through a free membership, represent their local interests through our National Ambassadors, and advocate on their behalf at the local, national, and international level. Results: ISAEM’s membership base is rapidly growing and our organization is currently represented by students in over 20 countries. In areas where the specialty of EM is not yet recognized, such as in Cameroon, ISAEM helped create the first EMIG and assists students with local projects. In countries where EM is new, such as Brazil, ISAEM helps students discover, explore, and advance this specialty. In countries where EM is thriving, like Canada, ISAEM offers students academic and personal opportunities to advance their careers and the specialty of EM internationally. Additionally, with the help of EM leaders worldwide, ISAEM has recently launched the FOAMed (Free Open Access Medical education) Translation Project and the International Observership Program. In the future, we aim to offer students international research, clinical, and mentorship programs, as well as more financial support. Conclusion: ISAEM is the international voice of medical student interested in promoting access to and expertise in emergency medical services worldwide. Through international collaboration, we hope to create an extensive network that will benefit medical students and the specialty of Emergency Medicine for many years to come.

Introduction: Collecting patient-reported follow-up data for prospective studies in the emergency department (ED) is challenging in this acute care, minimal continuity setting. Follow-up is frequently attempted using telephone contact and in some instances mail correspondence. The objective of this study was to determine if text messaging study participants involved in an ongoing randomized trial resulted in a lower rate of attrition as compared to conventional telephone follow-up. Methods: This was a secondary analysis of research participants enrolled in a randomized controlled trial assessing head injury discharge instructions. Adult (18-64 years) patients presenting to an academic ED (annual census 65,000) with chief complaint ‘head injury’ occurring within 24 hours of ED visit were contacted by telephone 2 and 4 weeks post ED visit to complete a symptom questionnaire. During the first 4 months of study follow-up, participants were contacted by a conventional telephone call. Attrition was higher than anticipated, thus we received subsequent ethics approval for the final 3 months of follow-up duration to contact participants by text message on the day of the first telephone attempt as a reminder of the telephone interview scheduled later that day. The proportion of patients lost to follow-up at 2 and 4 weeks post ED visit was compared between participants not receiving and receiving reminder text messages. Results: 118 patients were enrolled in the study (78 underwent conventional follow-up and 40 received text messages). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) were male. During the period of conventional follow-up, 3 participants withdrew from the study. Of the remaining 75 participants, 24 (32.0%) at 2 weeks and 32 (42.7%) at 4 weeks were unable to be contacted. Of the 40 participants receiving a reminder text message, 4 (10.0%) at 2 weeks and 10 (25.0%) at 4 weeks were unable to be contacted. Overall, text messaging study participants decreased attrition by 22% (95% CI: 5.9%, 34.7%) and 17.7% (95% CI: -0.8%, 33.3%) at 2 and 4 week follow-up, respectively. Conclusion: In this young ED cohort participating in a randomized trial, text message reminders of upcoming telephone follow-up interviews decreased the rate of attrition. Text messaging is a viable, low-cost communication strategy that can improve follow-up participation in prospective research studies.

Introduction: Diabetes mellitus affects over 2.7 million Canadians, with 90% being Type-2 diabetes (CDA 2010). Complications of diabetes are major causes for emergency department (ED) visits, adversely affecting patients’ health and costing the health system. Improving diabetes self-management can lead to avoidance of ED visits and revisits after discharge. Recent developments in mobile Health (mHealth), such as home health monitoring with sensors, social media, and text messaging, have shown promise in supporting patients in chronic disease self-management. This project tested the feasibility of these tools to support self-management for people with type-2 diabetes. Methods: Forty-three people with type-2 diabetes took part in a three month program that provided: health information via text messages, online access to curated resources and a facilitated discussion board, and access to wireless monitoring devices. Participants were outfitted with a wireless blood pressure monitor and weight scale, standard blood glucose monitor, and online access to their physiological data. Data collected included pre and post-self-reported health measures, tracking of physiological changes, website and discussion board use, cost survey, and interviews. Results: Participants reported significantly less health distress and an increase in diabetes empowerment. HbA1c levels decreased from an average of 7.41 to 6.77. Average weight and blood glucose also decreased over the study period. Interview and cost survey findings revealed most participants felt mDAWN provided good value; 78% expressed interest in continuing all or parts of the program. Interview findings revealed that participants developed self-management routines, and experienced increased self-awareness of, and ownership over, their health achievements. Conclusion: mHealth tools provided participants with their own physiologic information, connection with peers, and evidence informed advice. Participants highly valued this combination and improved their self-management and health outcomes. Equipping patients with similar tools for self-management post ED discharge holds great promise for decreasing revisits and improving health outcomes. This study has stimulated a clinical trial now underway to evaluate the effectiveness of home monitoring to facilitate the transition of patients between acute care and community settings.