Introduction: Increasingly, hospitals are adopting electronic charting systems. Recent literature suggests that physicians are spending roughly 2:1 hours on charting as compared to actual patient care raising questions as to whether manual electronic charting is the best use of scarce physician resources. To counter these effects, some hospitals have introduced scribes into their departments. A medical scribe is a person, or paraprofessional, who specializes in charting physician-patient encounters in real time. In this pilot study, we assessed the impact of having a scribe on the mental and physical fatigue, patient and healthcare-team engagement, and overall work satisfaction of emergency physicians at an urban emergency department (St. Paul’s Hospital, Saskatoon). Methods: Three research participants (emergency physicians) were recruited to the study. Each participant completed a typing test to determine typing skills. The student researcher then provided scribe services for each participant for two shifts. The scribe charted physician-patient interactions in real time and also completed order sets, wrote orders, imaging requisitions, and prescriptions. Physicians completed surveys after each shift with the scribe as well as after 2 shifts without a scribe (for a total of 12 shifts in the study, 6 with the intervention). Physicians were asked to rate their mental and physical fatigue, enjoyment of work, and impact on patient/team engagement on a 10-point Likert scale. Results from the questionnaires were analyzed to determine individual and group mean responses. Given the small sample size, no further statistical calculations were completed. Results: Typing test results (in words per minute) were as follows: Scribe 93, Physician A 64, Physician B 40, Physician C 25. In terms of both mental and physical fatigue post shift, all 3 participants recorded being less fatigued after working shifts with a scribe. Mean group scores were as follows: mental fatigue decreased by 33%, physical fatigue decreased by 23%. Physicians work enjoyment improved by 10%. Team and patient interaction did not seem impacted by the intervention. Conclusion: It appears that regardless of typing skills, all physician participants noted a measurable benefit from having a scribe on shift. This suggests that off-loading documentation to the scribe has a positive effect on mental and physical endurance. These results warrant further investigations.

Introduction: Cameras are a common in public spaces. London England is estimated to have 500,000 and Beijing China over 800,000. Smartphone penetration exceeds 60% of the population in 20 countries worldwide. Hundreds of sudden cardiac arrests are captured on video annually. This study searches publically available cardiac arrest videos with two objectives i) describe sudden cardiac arrest behaviour and ii) explore potential opportunities for machine learning. Methods: The search terms: “sudden death”, “heart attack”, “cardiac arrest” and “public death” were used. English sources included: Youtube.com, Dailymotion, vimeo.com, vidamax.com, LiveLeak.com and documentingreality.com Whereas, iqiyi.com, youku.com, le.com, fun.tv, pptv.com and tudou.com were searched using simplified Chinese. Inclusion criteria required that the subject in the video be completely visible five seconds prior to the event and at least ten seconds after and the quality of the video be adequate to visualize movement. Exclusion criteria included trauma or precipitating event (substance misuse, toxic exposure or asphyxiation). Each video source was searched until 30 consecutive irrelevant videos were obtained. Results: Four hundred and eighty eight videos met inclusion criteria. Of those videos, 112 could be confirmed as a “cardiac arrest” by at least two sources (news, or family social media account). In 53 (47%) of these videos the person touches their face or head within five seconds of collapse. Of the 98 videos where the person is upright, in 41 (37%) instances they hip-flexes and with their hands on their upper legs prior to collapse. This pattern of behaviour is combined in 36 (32%) instances. After collapse, 68 (61%) appeared to exhibit extension posturing activity. Agonal breathing was visible in 39 instances (35%). Conclusion: Sudden out of hospital cardiac arrest has a recognizable pattern. This represents an opportunity for machine learning, using shape tracking and edge detection, to recognize this event and activate the emergency response system.

Introduction: Following life-threatening hemorrhage the goal is to temporize blood-loss and expedite definitive-rescue. Junctional (abdominal-pelvic) trauma, between the inguinal ligament and umbilicus; is a leading cause of potentially survivable mortality. Numerous devices such as junctional tourniquets and resuscitative endovascular balloon occlusion of the aorta have been suggested for this injury pattern, but we propose an immediately available and expedient bimanual maneuver that may act as a bridge to device application, proximal external aortic compression (PEAC). Of note, external aortic compression has been used for centuries in life-threatening postpartum hemorrhage. Methods: Twelve paramedic volunteers were recruited from a continuing education event. Participant demographics, blood pressure, abdominal circumference, body mass index and procedural discomfort were recorded. In pairs, six participants were taught PEAC and performed the maneuver, then exchanged roles. Training consisted of researcher led demonstration and participant return demonstration with feedback. The duration of training was less than five minutes for all participants. Femoral artery hemostasis was measured by doppler ultrasound. Results: Participant mean age was 28.6 (range 22 to 46) and their mean systolic blood pressure was 128.25 mmHg (range 102 to 145). Mean body mass index was 24 (range 22 to 28) and abdominal girth was 80 cm (range 70 to 110). Bilateral common femoral artery blood flow became undetectable in all participants, by doppler ultrasound. Participant discomfort was reported as a mean of 4.4 (range 3 to 6) on a zero to ten scale. No complications were reported with seven and 30 days follow-up. Conclusion: This study demonstrates successful PEAC in twelve healthy participants. However, our limitations include a small sample and the relatively modest abdominal circumferences of our participants. If light of these limitations, PEAC may be a potentially life-saving maneuver which is immediately deployable and easy to learn, for patient temporization until device application and/or operative rescue.

Introduction: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the emergency department (ED) accounting for significant morbidity, mortality and health care resource usage. In Alberta, a provincial care pathway was recently developed to provide an evidence informed approach to managing patients with an UGIBs in the ED. Pantoprazole infusions are a commonly used treatment despite evidence that suggests they are generally not indicated prior to endoscopy in the ED. The goal of this project was to optimize management of patients with a NVUGIB, in particular reduce pre-endoscopy pantoprazole infusions. Methods: In July 2016, we implemented a multi-faceted intervention to optimize management of ED patients with NVUGIB including 1. de-emphasizing IV pantoprazole infusions in the ED, 2. clinical decision support (CDS) embedded (for endoscopy, disposition and transfusions) within the order set and 3. educating clinicians about the care pathway. We used a pre/post-order set design, analyzing 391 days pre and 189 days post-order set changes. Data was extracted from our fully integrated electronic health records system. The primary outcome was the % of patients receiving IV pantoprazole infusion ordered by an emergency physician (EP) among all patients with NVUGIB. Secondary outcomes included % transfused with hgb >70g/L and whether using the GIB order set impacted management of NVUGIB patients. Results: In the 391 days pre-order set changes, there were 2165 patients included and in the 189 days post-order set changes, there were 901 patients. For baseline characteristics, patients in the post-order set change group were significantly older (64.4 yrs vs 60.9 yrs p-value=0.0016) and had a lower hgb (115 vs 118, p-value=0.049) but otherwise for gender, measures of severity of illness (systolic blood pressure, heart rate, CTAS, % admitted) there were no significantly differences. For the primary outcome, in the pre-order set phase, 47.1% received a pantoprazole infusion ordered by an EP, compared to 31.5% in the post-order phase, for an absolute reduction of 15.6% (p-value= <0.001). For the secondary outcomes, transfusion rates were similar pre/post (22.08% vs 22.75%). Significant inter-site variability exists with respect to the reduction in pantoprazole infusion rates across the four sites (-23.3% to +6.12%). Conclusion: Our interventions resulted in a significant overall reduction in pantoprazole infusions in ED patients with NVUGIB. Reductions in pantoprazole infusions varied significantly across the different sites, future work in our department will explore and address this variability. Keys to the success of this project included engaging clinicians as well as leveraging the SCM order sets as well as the provincial care pathway. Although there were no changes in transfusion rates, it in unclear if this a function of the CDS not being effective or whether these transfusions were clinically indicated.

Introduction: There is a growing interest in providing clinicians with performance reports via audit and feedback (A&F). Despite significant evidence exists to support A&F as a tool for self-reflection and identifying unperceived learning needs, there are many questions that remain such as the optimal content of the A&F reports, the method of dissemination for emergency physicians (EP) and the perceived benefit. The goal of the project was to 1. evaluate EP perceptions regarding satisfaction with A&F reports and its’ ability to stimulate physicians to identify opportunities for practice change and 2. identify areas for optimization of the A&F reports. Methods: EP practicing at any of the four adult hospital sites in Calgary were eligible. We conducted a web survey using a modified Dillman technique eliciting EP perspectives regarding satisfaction, usefulness and suggestions for improvement regarding the A&F reports. Quantitative data were analyzed descriptively and free-text were subjected to thematic analysis. Results: From 2015 onwards, EP could access their clinical performance data via an online dashboard. Despite the online reports being available, few physicians reviewed their reports stating access and perceived lack of utility as a barrier. In October 2016, we began disseminated static performance reports to all EP containing a subset of 10 clinical and operational performance metrics via encrypted e-mail. These static reports provided clinician with their performance with peer comparator data (anonymized), rationale and evidence for A&F, information on how to use the report and how to obtain continuing medical education credits for reviewing the report. Conclusion: Of 177 EP in Calgary, we received 49 completed surveys (response rate 28%). 86% of the respondents were very/satisfied with the report. 88% of EP stated they would take action based on the report including self-reflection (91%) and modifying specific aspects of their practice (63%). Respondents indicated that by receiving static reports, 77% were equally or more likely to visit the online version of the eA&F tool. The vast majority of EP felt that receiving the A&F reports on a semi-annual basis was preferred. Three improvements were made to the eA&F based on survey results: 1) addition of trend over time data, 2) new clinical metrics, and 3) optimization of report layout. We also initiated a separate, real-time 72-hour bounceback electronic notification system based on the feedback. EP value the dissemination of clinical performance indicators both in static report and dashboard format. Eliciting feedback from clinicians allows iterative optimization of eA&F. Based on these results, we plan to continue to provide physicians with A&F reports on a semi-annual basis.

Introduction: To describe dosing, duration, and pre- and post-infusion analgesic administration of continuous intravenous sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful conditions in the emergency department (ED). Methods: Retrospective chart review of patients aged 18 and older presenting to the ED with acute and chronic painful conditions who received continuous SDK infusion in the ED for a period over 6 years (2010-2016). Primary data analyses included dosing and duration of infusion, rates of pre- and post-infusion analgesic administration, and final diagnoses. Secondary data included pre- and post-infusion pain scores and rates of side effects. Results: 104 patients were enrolled in the study. Average dosing of ketamine infusion was 11.26 mg/hr, the mean duration of infusion was 135.87 minutes with 38% increase in patients not requiring post-infusion analgesia. The average decrease in pain score was 5.04. There were 12 reported adverse effects with nausea being the most prevalent. Conclusion: Continuous intravenous SDK infusion has a role in controlling pain of various etiologies in the ED with a potential to reduce need for co-analgesics or rescue analgesic administration. There is a need for more robust, prospective, randomized trials that will further evaluate the analgesic efficacy and safety of this modality across wide range of pain syndromes and different age groups in the ED.

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two Canadian tertiary care Emergency Departments (ED) between June 2014 to July 2016. The goals were to improve patient care by increasing value and reducing waste. Longer times to physician initial assessment (PIA), ED length of stays (LOS) and times to inpatient beds are associated with increased patient morbidity and potentially mortality. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards and a novel initial assessment process ED access block has limited full implementation of EDST. An interim analysis was conducted to assess impact of interventions implemented to date on flow metrics. Methods: Daily ED visit volumes, boarding at 7am, time to PIA and LOS for non-admitted patients were collected from April 2014 -June 2016. Volume and boarding were compared from first to last quarter using an independent samples median test. Linear regression for each variable versus time was conducted to determine unadjusted relationships. PIA, LOS for non-admitted low acuity (Canadian Triage and Acuity Scale (CTAS) 4,5) and non-admitted high acuity (CTAS 1,2,3) patients were subsequently adjusted for volume and/or boarding to control for these variables using a non-parametric correlation. Results: Overall, median ED boarding decreased at University Hospital (UH) (14.0 vs 6.0, p<0.01) and increased at Victoria Hospital (VH) (17.0 vs 21.0, p<0.01) from first to last quarter. Median ED volume increased significantly at UH from first to last quarter (129.0 vs 142.0, p<0.01) but remained essentially unchanged at VH. 90th percentile LOS for non-admitted low acuity patients significantly decreased at UH (adjusted rs=-0.24, p<0.01) but did not significantly change at VH. For high acuity patients 90th percentile LOS significantly decreased at both hospitals (UH: adjusted rs=-0.23, p<0.01; VH: adjusted rs=-0.21, p<0.01). 90th percentile time to PIA improved slightly but significantly in both EDs (UH: adjusted rs=-0.10, p<0.01; VH: adjusted rs=-0.18, p<0.01). Conclusion: Persistent ED boarding impacted the ability to fully implement the EDST model of care. Partial EDST implementation has resulted in improvement in PIA at both LHSC EDs. At UH where ED boarding decreased, LOS metrics improved significantly even after controlling for boarding.

Introduction: Improving public access and training for epinephrine auto-injectors (EAIs) can reduce time to initial treatment in anaphylaxis. Effective use of EAIs by the public requires bystanders to respond in a timely and proficient manner. We wished to examine optimal methods for effective training and skill retention for public use of EAIs. Methods: In this prospective, stratified randomized study, 154 participants at 15 sites receiving installation of public EAIs were randomized to one of three experimental education interventions: A) didactic poster (POS) teaching; B) poster with video teaching (VID), and C) Poster, video, and simulation training (SIM). Participants were tested by participation in a standardized simulated anaphylaxis scenario at 0-months, immediately following training, and again at follow-up at 3 months. Participants responses were videoed and assessed by blinded raters. Patient recorded experience measures (PREMs) assessed participant-patient interaction for every scenario. Data that was non-normally distributed was analyzed using non-parametric testing (Kruskall-Wallis-Rank Sum-Test). Results: Initial analysis showed differences between group baseline characteristics for age and first aid training; with a multivariable analysis providing the effect size of these differences. PREM data and video assessment data were not normally distributed. Analysis of PREM data revealed significantly higher scores in the SIM group at 0-months (median=6.5, IQR=5; p=0.05) and 3-months (median=5, IQR=3; p<0.01), compared to those groups that did not receive SIM. Video assessment performance scores show trends in higher skills and knowledge retention for SIM participants at 3-months; full data analysis will be performed at a later date. Final video assessment analysis will involve a weighted scoring system, using a consensus process, and an inter-rater agreement analysis. Conclusion: Simulation training improves interaction, essential skills, and retention of knowledge in simulated anaphylaxis response with public EAIs compared to non-simulation-based training.

Introduction: Interest groups have become increasingly popular as students explore potential career paths earlier in their undergraduate experience. Emergency medicine (EM) has grown as a specialty and the match has become quite competitive. Attractive features of EM cited by learners (diversity, procedural skills and flexible schedule) appeal broadly to the undergraduate population. Learners at Memorial University recognized this leadership opportunity and worked with faculty to reach this wide target audience through a streamlined iterative evaluation of their EM Interest Group (EMIG). Methods: The local EMIG was formed in 2010. Yearly, EMIG executive work with outgoing members using prior experiences, contacts and best practices to facilitate handover and progress. From 2015 to present, 305 surveys were collected, giving an 81.9% response rate. 59.7% of respondents were first year students, and 40.3% were second year. The survey consisted of Likert scale and open-response questions. The Likert scale questions yielded favorable responses. 304 students (99.6%) felt presenters were knowledgeable, 301 (98.6%) would recommend the sessions to others and 301 (98.6%) were satisfied they attended. Surprisingly, 133 students (43.6%) said they were not interested in Emergency Medicine, likely attending due to the appeal of session topics and transferrable of EM skills. 232 (76.0%) stated that attendance did increase their interest in EM. Top responses for aspects of EM most interesting to them included: ability to find a work/life balance, ability to work urban or rural, variety of cases seen, and the non-routine shifts. Results: Survey feedback is used to inform refinement of the content, delivery and format of EMIG activities, delivered by EM faculty. Hands-on sessions (eg. suturing & airway management) have been popular. Informational sessions, on specific medical topics (ECG, resuscitation cases) or broader topics (EM streams) have also been very well received. Inclusion of all interested students, particularly large numbers for hands-on sessions, has presented challenges. Beyond current survey results, it will be interesting to consider if EMIG participation translates to learning or behavioral changes relevant to later clinical encounters; a question that will be difficult to quantify. Conclusion: The EM interest group is one of the most active at Memorial University. Survey results indicate that participants enjoy the EMIG session content and the structured iterative approach used by the group has been successful in maintaining an effective student led organization.

Introduction: Safe and efficient provision of quality healthcare requires maintenance of knowledge and skills relevant to daily practice. This is particularly relevant in rural and remote locations where high-acuity low-occurrence procedures and clinical scenarios present even less frequently. Simulation based training is widely used to supplement clinical exposure and practice but effective delivery of this approach to the rural/ remote practitioner must address barriers of time, cost and geographical separation. Mobile tele-simulation is an innovative approach that may help in bridging the gap through delivery of effective mentoring using telemedicine technologies and tailored educational content. Methods: To help direct the iterative design cycle for the mobile tele-simulation unit, input from potential future users was felt to be essential. The Delphi method was employed to reach consensus among study participants on four key questions: 1) What applications would the MTU be best suited for?, 2) What technical requirements and teaching tools would be needed to make the MTU successful?, 3) Which fields, besides EM/medical education, may benefit from partnerships with the final MTU?, 4) What research studies could be developed using the MTU? It was decided in advance that two rounds would be the maximum due to time constraints of the larger MTU projects. The first questionnaire focused on demographics and the four questions above. Independent reviewers analyzed, compiled and compared responses. Participants were sent the updated list, asked to confirm their responses and then to rank the responses highest to lowest priority. Results: Fifteen of 17 first round participants completed the questions, giving an 88.2% response rate. All shared a simulation background. 66% were physicians, 13.3% medical students, and 20% staff at Memorials Simulation Center. 66% had been involved with simulation-based education less than 5 years, and the others greater than 5 year. 13 of 15 (86.7%) responded in round 2. Consensus was not reached statistically using Kendalls W test for each of the four questions. However, there were several responses that showed higher median ranks than the others under each question. Application use: rural healthcare training, and medical professional training Technical factors: reliable learner-mentor connection, and competent technical support Non-technical factors: knowledgeable mentor and content relevant to locations practice, Research studies: training needs assessment from rural sites, and learners experience compared to stationary simulation center Conclusion: Input from a heterogeneous group of simulation users was sought to help prioritize key features in the development of the Mobile Tele-simulation Unit. Although statistically the study did not reach consensus, valuable feedback was compiled and pragmatically applied in the iterative development cycle.

Introduction: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Canada. The Anthonisen criteria utilizes the cardinal symptoms of acute exacerbations of COPD (AECOPD), increased shortness of breath, increased sputum production, and increased sputum purulence, to determine which patients should receive antibiotics. In July 2015, a COPD Order Set Pilot was implemented in Saskatoon emergency departments (ED). The order set utilizes the Anthonisen criteria to optimize AECOPD patient management and ensure appropriate antibiotic usage. By January 2019, we aim to optimize AECOPD patient management in Saskatoon ED. We aim to increase physician uptake of the order set to 50% and to increase appropriate antibiotic prescription to 90%. Methods: Our project was designed following the Plan-Do-Study-Act method. Our primary outcome was to measure the rate of appropriate antibiotic prescription when managing AECOPD patients. Our secondary outcome was to measure physician uptake of the order set. We believed that a standardized order set would optimize patient care. We hypothesized that 80% of AECOPD patients would be managed with antibiotics appropriately and that 25% of emergency physicians would utilize the order set. A chart review was conducted examining AECOPD patient management in Saskatoon ED. The study period included the 6 months following the implementation of the order set. Our inclusion criteria were patients diagnosed with AECOPD and managed in the ED. Our exclusion criteria were patients currently prescribed antibiotics or patients requiring inpatient admission. A convenience sample of 125 charts was selected for review, enabling an accurate representation of order set utilization and antibiotic usage. A secondary reviewer abstracted a random 15% sample of the charts to ensure validity of the data. Results: Our results showed that, during our study period, none of the AECOPD patients were managed with the order set. Of the patients receiving antibiotic therapy, only 32 of the 53 (60.38%) met the Anthonisen criteria and were appropriately prescribed antibiotics. Of the patients not given antibiotics, 15 of the 42 (35.71%) met the Anthonisen criteria and should have been managed with antibiotics. These results refuted both of our hypotheses. Conclusion: As COPD is one of the leading causes of morbidity and mortality in Canada, proper management is crucial. Our results state that uptake of the order set is low and that antibiotic utilization is not optimized. These results demonstrate the need to modify and promote the current order set. We believe that by encouraging the use of the order set and streamlining the management guidelines, we can increase physician uptake. This will subsequently increase appropriate antibiotic prescription and improve AECOPD patient care. A second identical chart review for 2017 has been completed. Data analysis will be finalized prior to the conference.

Introduction: Acute atrial fibrillation (AAF) is the most common arrhythmia managed in the Emergency Department (ED). Direct costs of AAF are primarily attributed to ED visits and subsequent admission to hospital. A better understanding of patients attitudes regarding ED attendance is necessary to develop strategies to improve the patient care experience while simultaneously reducing ED presentation and inappropriate hospital admissions. This study aims to describe patient perspectives on ED use for AAF using in-depth qualitative interviews. Methods: An interview template designed to explore why patients attend the ED for AAF was constructed based on the Theoretical Domains Framework, a theory-informed approach that utilizes 14 domains to describe influencers of behavior. We conducted audio-recorded, semi-structured interviews of patients following their presentation to the ED for management of AAF. Interviews were anonymized, transcribed and imported into NVivo for coding and analysis. Two independent reviewers used a direct approach to code participant statements. Discrepancies were resolved by a third party. Belief statements were generated and relevant domains identified based on high frequency scores, conflicting belief statements or evidence of strong influencing beliefs. Results: 12 patient interviews, mean age 63.1 years, 91.7% male, 75.0% recurrent AAF, were completed. Patients stated that they attended the ED because: 1) symptom severity; 2) they were instructed by physicians to attend the ED should their AAF recur; and 3) they were encouraged by family members to attend. Their primary goal was to have relief of their symptoms. There was no expectation of specialist consultation or admission to hospital. Even though most patients stated they were open to managing these episodes independently, they reported that they did not have the knowledge or tools to do so. Conclusion: Patients with AAF present to the ED because of their symptom burden, social influences (physician and family) and lack of other management options. This study demonstrates the need for development of patient self-management strategies which will empower patients in their disease management and may decrease future ED visits.

Introduction: Trauma leading to uncontrolled hemorrhage of the torso in the critically injured patient can rapidly progress to decreased cerebral and cardiovascular perfusion and carries a significant morbidity and mortality. Given the non-compressible nature and difficult anatomic access of these injuries, obtaining hemostasis is often a challenge and non-surgical options are sparse. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a rapidly administered emergency department intervention that allows transient source control of caudal torso hemorrhage while arranging definitive surgical management. Although initially postulated in the 1950s, limited research regarding its therapeutic use in trauma has been available until recently. Here, we present a systematic review of the literature pertaining to the use of REBOA in severe trauma. Methods: An experienced medical librarian searched electronic databases for terms relating to REBOA, aortic balloon occlusion, hemorrhage, trauma and shock. Articles were identified, screened, retrieved and reviewed in accordance with PRISMA systematic review guidelines. English case reports, case series, cohort studies, randomized-controlled trials, systematic reviews and meta-analyses pertaining to the use of REBOA in human trauma patients were included. Customized inclusion and data extraction forms were created and used to form an electronic database of relevant studies. Results: After exclusion of duplicates, 2147 potentially relevant articles were identified and screened by title/abstract and 136 articles meeting inclusion criteria were retrieved for full-text review. Final analysis of 26 articles included 5 case reports, 13 case series, 7 observational cohort studies and 1 systematic review. Data spanning 771 patients undergoing REBOA were collected (weighted average age: 49.5, gender: 67.7% male, injury severity score: 35.1). Where data available, REBOA increased systolic blood pressure by a weighted average of 54.7mmhg and overall survival was 32.6%. Conclusion: Limited evidence pertaining to the use of REBOA in severe trauma exists with the majority of available data coming from individual case studies and case series. By extension, quantitative analysis regarding outcome data of this intervention requires further research in the form of larger studies with subgroup analysis to identify the subset of patients for which REBOA may benefit and to further delineate the risks of implementing this intervention

Introduction: Emergency departments (ED) across Canada acknowledge the need to transform in order to provide high quality care for the increasing proportion of older patients presenting for treatment. Older people are more complex than younger ED users. They have a disproportionately high use of EDs, increased rates of hospitalization, and are more likely to suffer adverse events. The objective of this initiative was to develop minimum standards for the care of older people in the emergency department. Methods: We created a panel of international leaders in geriatrics and emergency medicine to develop a policy framework on minimum standards for care of older people in the ED. We conducted a literature review of international guidelines, frameworks, recommendations, and best practices for the acute care of older people and developed a draft standards document. This preliminary document was circulated to interdisciplinary members of the International Federation of Emergency Medicine (IFEM) geriatric emergency medicine (GEM) group. Following review, the standards were presented to the IFEM clinical practice group. At each step, verbal, written and online feedback were gathered and integrated into the final minimum standards document. Results: Following the developmental process, a series of eight minimum standard statements were created and accepted by IFEM. These standards utilise the IFEM Framework for Quality and Safety in the ED, and are centred on the recognition that older people are a core population of emergency health service users whose care needs are different from those of children and younger adults. They cover key areas, including the overall approach to older patients, the physical environment and equipment, personnel and training, policies and protocols, and strategies for navigating the health-care continuum. Conclusion: These standards aim to improve the evaluation, management and integration of care of older people in the ED in an effort to improve outcomes. The minimum standards represent a first step on which future activities can be built, including the development of specific indicators for each of the minimum standards. The standards are designed to apply across the spectrum of EDs worldwide, and it is hoped that they will act as a catalyst to change.

Introduction: Our study objectives were to assess the acceptability of using the emergency department (ED) waiting room to provide knowledge on, and offer opportunities for organ and tissue donor registration; and to identify barriers to the donor registration process in Ontario. Methods: We conducted a paper based in-person survey over nine days for eight hour blocks in March and April 2017. The survey instrument was created in English using existing literature and expert opinion, pilot tested and then translated into French. The study collected data from patients and visitors in an urban academic Canadian tertiary care ED waiting room. All adults in the waiting room were approached to participate during the study periods. Individuals waiting in clinical care areas were excluded, as well as those who required immediate treatment. Results: The number of attempted surveys was 324; 67 individuals (20.7%) refused to partake. A total of 257 surveys were distributed and five were returned blank. This gave us a response rate of 77.8% with 252 completed surveys. The median age group was 51-60 years old with 55.9% female. Forty-six percent were Christian (46.0%) and 34.1% did not declare a religious affiliation. Nearly half of participants (44.1%) were registered organ donors. The majority of participants agreed or were neutral (83.3%) that the ED waiting room was an acceptable place to provide information on organ and tissue donation. Further, 82.1% agreed or were neutral that the ED was an acceptable place to register as an organ donor. Nearly half (47.2%) agreed that they would consider registering while in the ED waiting room. A number of barriers to registering as an organ and tissue donor were identified. The most common were: not knowing how to register (22.0%), a lack of time to register (21.1%), and having unanswered questions regarding organ and tissue donation (18.7%). Conclusion: Individuals waiting in the ED are supportive of using the ED waiting room for distributing information regarding organ and tissue donation, and facilitating organ and tissue donation registration. Developing such a practice could help to reduce some of the identified barriers, including a lack of time and having unanswered questions regarding donation.

Introduction: Endotracheal intubation is frequently used in emergency departments and is often life saving, but it is also known to cause adverse events that can potentially lead to death. The main objective of this study is to evaluate mortality rates and duration of hospitalisation in patients who experienced post-intubation hypotension (PIH). Methods: A historical cohort of patients admitted between 07/2011 and 11/2014 at the ED of a level-one trauma centre. Patients were included if they were aged 16 years old or more, were intubated in the resuscitation room,had less than 3 intubation attempts, no need of surgical airway access, and had recorded vital signs prior to intubation. All clinical data including vitals were prospectively collected using ReaScribe®. PIH was defined by one measure or more of systolic arterial blood pressure <90 mm Hg. We retrospectively analysed the occurrence of PIH at 4 time points : 5, 15, 30 minutes, and at any moments after intubation. Study outcomes were in-hospital death and hospital length of stay in days (LOS). Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: 261 patients were included in the analyses. Amongst patient who experienced PIH, incidence of mortality was, respectively for each time estimate, of 31,0%, 33,3%, 28,6% and 26,9 % compared to 25,4% (p=0,5), 24,2% (p=0,1), 24,9% (p=0,5), and 25,4 % (p=0,8) in the normotensive group. The mean duration of hospitalisation in the group exposed to PIH was respectively of 26 (12,9-53,3), 22 (13,5-35,5), 19 (13,6-27,8), and 18 days (13.5-24.8) compared to 15,6 (12,9-18,9), 15,4 (12,6-18,8), 15,3 (12,3-19,1), and 15,5 (12.1-19.7) days (p=0,4). Conclusion: There was no association between the presence of post-intubation hypotension at 4 different time estimates and the in-hospital mortality nor the hospital length of stay. Further evaluation in specific sub-group should be foreseen to prevent adverse events from endotracheal intubation.

Introduction: It is estimated that up to 30% of medical services in Canada are potentially unnecessary, not supported by current evidence or may cause patient harm. This type of practice negatively impacts patients and the healthcare system. Evidence suggests that medical education strongly impacts resource utilization in future practice. Our objective was to integrate Choosing Wisely (CW) recommendations into the undergraduate medical education curriculum to improve students understanding of resource stewardship in their pre-clerkship training. Methods: Post-course survey data and written feedback were collected from the Cumming School of Medicines 2019 class. Qualitative analysis of written feedback was used to identify perceived strengths and areas of improvement to inform additional changes for the 2020 class through a Plan-Do-Study-Act (PDSA) cycle. Results: The post-course survey was completed by 143 students. 60% reported the inclusion of CW improved their ability to develop a clinical management plan. Using the information gathered from the qualitative analysis, we made the following changes for the 2020 class: create an introductory lecture on resource stewardship, incorporate relevant CW recommendations into case study learning objectives, and create standardized slides on CW recommendations for lecturers. Feedback from the 2020 class revealed that the changes were well received and students reported feeling more comfortable with resource stewardship concepts. Conclusion: This data reveals that our efforts have increased students confidence in creating a management plan that integrates resource stewardship and patient safety, and elicited strong faculty support. We will continue to integrate these changes and to obtain student and faculty feedback to help inform additional iterative changes for the subsequent cohort. Our findings are valuable for other medical schools across Canada seeking to incorporate CW material.

Introduction: Hypertension is common and a major cause of morbidity and mortality. Because it is asymptomatic, its diagnosis is often delayed. For many Canadians the Emergency Department (ED) is the only point of entry to the health care system, and therefore the recognition of undiagnosed and untreated hypertension in the ED is increasingly important. This study sought to evaluate the prevalence and severity of hypertension in patients presenting to Calgary area EDs, as well as to determine whether medical therapy was initiated and if patients had primary care providers for follow-up. Methods: Multi-centre electronic medical record (EMR) review of all adult patients presenting to Calgary area EDs from January 1, 2016 to December 31st, 2016. Hypertension was coded electronically by triage nurses and defined as systolic blood pressure SBP 140 mmHg and/or diastolic blood pressure DBP 90 mmHg. Hypertensive urgency was defined as SBP 180 mmHg and/or DBP 120 mmHg. Descriptive data was used to show patient demographics and hypertension prevalence. Primary care provider status, previous diagnosis of hypertension, chief complaint, and ED diagnoses were extracted and the EMRs were manually searched to determine whether treatment was initiated in the ED. Results: Of 304392 patients presenting to all Calgary sites, 43055 (14%) were found to have hypertension; mean age 52 (range 18 to 104), female 42%. Of these, 32986 (77%) had no known previous hypertension and 31% lacked a primary care provider. 0.2% had documentation of treatment initiated in the ED. 16% met criteria for hypertensive urgency. Conclusion: Many patients presenting to the ED have hypertension, often previously undiagnosed and at times severe. Many lack access to primary care. EDs may play an important role in the early recognition of hypertension. Dedicated management and follow-up pathways are indicated for this high-risk population.

Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Microskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Surgical cricothyrotomy is a rarely performed safety critical task. Methods: Two doctors and three nurses developed stepwise team microskills checklists from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 30 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. Commonly available airway trainers were retrofitted with the 3-D printed larynx. The microskills checklist was used in four phases: 1. Group discussion of each microskill step; 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback - changes are recorded; 3. Total task run through without interruption - changes are recorded; 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 12/21, RNs 6/12. The commonest changes in practice were equipment preparation (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 5/5). Conclusion: Microskills checklists facilitate cricothyrotomy skill development in interprofessional teams in this provisional analysis.

Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.