Introduction: Previous systematic reviews suggest early mobilization in the intensive care unit (ICU) population is feasible, safe, and may improve outcomes. Only one review investigated mobilization specifically in trauma ICU patients and failed to identify any relevant articles. The objective of the present systematic review was to conduct an up-to-date search of the literature to assess the effect of early mobilization in adult trauma ICU patients on mortality, length of stay (LOS) and duration of mechanical ventilation. Methods: We performed a systematic search of four electronic databases (Ovid MEDLINE, Embase, CINAHL, Cochrane Library) and the grey literature. To be included, studies must have compared early mobilization to delayed or no mobilization among trauma patients admitted to the ICU. Meta-analysis was performed to determine the effect of early mobilization on mortality, hospital LOS, ICU LOS, and duration of mechanical ventilation. Results: The search yielded 2,975 records from the 4 databases and 7 records from grey literature and bibliographic searches; of these, 9 articles met all eligibility criteria and were included in the analysis. There were 7 studies performed in the United States, 1 study from China and 1 study from Norway. Study populations included neurotrauma (3 studies), blunt abdominal trauma (2 studies), mixed injury types (2 studies) and burns (1 study). Cohorts ranged in size from 15 to 1,132 patients (median, 63) and varied in inclusion criteria. Most studies used some form of stepwise progressive mobility protocol. Two studies used simple ambulation as the mobilization measure, and 1 study employed upright sitting as their only intervention. Time to commencement of the intervention was variable across studies, and only 2 studies specified the timing of mobilization initiation. We did not detect a difference in mortality with early mobilization, although the pooled risk ratio (RR) was reduced (RR 0.90, 95% CI 0.74 to 1.09). Hospital LOS and ICU LOS were decreased with early mobilization, though this difference did not reach significance. Duration of mechanical ventilation was significantly shorter in the early mobilization group (mean difference −1.18. 95% CI −2.17 to −0.19). Conclusion: Our review identified few studies that examined mobilization of critically ill trauma patients in the ICU. On meta-analysis, early mobilization was found to reduce duration of mechanical ventilation, but the effects on mortality and LOS were not significant.

Introduction: Early and accurate diagnosis of critical conditions is essential in emergency medical services (EMS). Serum lactate testing may be used to identify patients with worse prognosis, including sepsis. Recently, the use of a point-of-care lactate (POCL) test has been evaluated in guiding treatment in patients with sepsis. Operating as part of the Prehospital Evidence Based Practice (PEP) Program, the authors sought to identify and describe the body of evidence for POCL use in EMS and the emergency department (ED) for patients with sepsis. Methods: Following PEP methodology, in May 2018, PubMed was searched in a systematic manner. Title and abstract screening were conducted by the program coordinator. These studies were collected, appraised and added to the existing body of literature contained within the PEP database. Evidence appraisal was conducted by two reviewers who assigned both a level of evidence (LOE) on a novel three tier scale and a direction of evidence (supportive, neutral or opposing; based on primary outcome). Data on setting and study design were also extracted. Results: Eight studies were included in our analysis. Three of these studies were conducted in the ED setting; each investigating the POCL test's ability to predict severe sepsis, ICU admission or death. All three studies found supportive results for POCL. A systematic review on the use of POCL in the ED determined that this test can also improve time to treatment. Five of the total 8 studies were conducted prehospitally. Two of these studies were supportive of POCL use in the prehospital setting; in terms of feasibility and the ability to predict sepsis. Both of these study sites used this early information as part of initiating a “sepsis alert” pathway. The other three prehospital studies provide neutral support for POCL. One study demonstrated moderate ability of POCL to predict severe illness. Two studies found poor agreement between prehospital POCL and serum lactate values. Conclusion: Limited low and moderate quality evidence suggest POCL may be feasible and helpful in predicting sepsis in the prehospital setting. However, there is sparse and inconsistent support for specific important outcomes, including accuracy.

Introduction: In 2016, a team at McMaster began developing GridlockED, an educational (or “serious”) board game designed to teach medical learners about patient flow in the emergency department. As serious board games are a relatively new phenomenon in medical education, there is little data on how marketed games are actually used once received by end-users. In this study our goal was to better understand the demographics and game usage for purchasers of the GridlockED board game, which will inform the further improvement or expansion of the game. Methods: Individuals who expressed interest in purchasing gridlockED via our online storefront were sent an anonymous online survey via Google Form. The survey collected demographic and qualitative data with a focus on the respondent's role in medicine, how they have used GridlockED, who they have played GridlockED with, and what changes or additions to GridlockED they would like to see. We also asked about changes for a potential mass-market version of the game targeted towards non-medical individuals. Individuals who did not purchase the game were asked about their barriers to purchase. We received an exemption for this study from our institutional review board. Results: 42 responses (out of 300 individuals on our mailing list, 14% response rate) were collected. Responding purchasers were from 16 different roles in healthcare and 11 different countries. The top 5 roles were: EM trainee, Community EM MD, Academic EM MD, Physicians from other specialties, and EM program director. The majority of respondents were Canadian (38%), with America (21%), New Zealand (10%), and Turkey (7%) the only other countries to have more than 2 respondents. 50% reported having played the game, with the most common use cases being for fun (76%), for teaching trainees (33%) or training with colleagues (19%). For those who did not purchase, price was the largest barrier (81%). 50% of respondents expressed interest in a disaster scenario expansion pack, with 33% interested in set lesson plans. Conclusion: GridlockED attracted interest from a wide range of medical professionals, both in terms or role and location. Users mainly reported using the game for fun, with fewer users using the game for teaching/training purposes. The main barrier to purchase was the game's price.

Introduction: Chest tube insertion, a critical procedure with a published complication rate (30%), is a required competency for emergency physicians. Microskills training has been shown to identify steps that require deliberate practice. Objectives were: 1. Develop a chest tube insertion microskills checklist to facilitate IPE, 2. Compare the microskills checklist with published best available evidence, 3. Develop an educational video based on the process map, 4. Evaluate the video in an interprofessional team prior to cadaver training as a proof of concept. Methods: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student). A final microskills list was produced and compared to the procedural steps described in consensus publications. An educational video was produced and evaluated by an interprofessional team prior to cadaver training using a survey and Likert scales as a proof of concept. Participants were 7 EM RNs and 6 ATLS trained physicians. Participants were asked to fill out a nine-question survey, using a 5-point Likert Scale (1-strongly disagree to 5 strongly agree). Results: The final process map contained 54 interdisciplinary steps, compared to ATLS that describes 14 main steps and peer reviewed articles that describe 9 main steps. The microskills checklist described, in more detail, the steps that relate to team interaction and the operational environment. Physicians rated the training video were able to apply what they learned in the video with an average of 4.67 (median of 5, mode of 5, and an IQR of 0.75). Conclusion: The development of the process maps and microkills checklists provides interprofessional teams with more information about chest tube insertion than instructions described in commonly available courses and procedural steps derived by consensus.

Introduction: Emergency Department (ED) visits related to substance use are rapidly increasing. Despite this, few Canadian EDs have immediate access to addiction medicine specialists or on-site addiction medicine clinics. This study characterized substance-related ED presentations to an urban tertiary care ED and assessed need for an on-site rapid-access addiction clinic (RAAC). Methods: This prospective enrollment, retrospective chart review was conducted from June to August 2018. Adult patients presenting to the ED with a known or suspected substance use disorder were enrolled by any member of their ED care team using a 1-page form. Retrospective chart review of the index ED visit was conducted and the Emergency Department Information System was used to extract information related to the visit. A multivariable logistic regression model was fit to examine factors associated with recommendation for referral to a hypothetical on-site RAAC.This prospective enrollment, retrospective chart review was conducted from June to August 2018. Adult patients presenting to the ED with a known or suspected substance use disorder were enrolled by any member of their ED care team using a 1-page form. Retrospective chart review of the index ED visit was conducted and the Emergency Department Information System was used to extract information related to the visit. A multivariable logistic regression model was fit to examine factors associated with recommendation for referral to a hypothetical on-site RAAC. Results: Of the 557 enrolment forms received, 458 were included in the analysis. 64% of included patients were male and 36% were female, with a median age of 35.0 years. Polysubstance use was seen in 23% of patients, and alcohol was the most common substance indicated (60%), followed by stimulants (32%) and opioids (16%). The median ED length of stay for included patients was 483 minutes, compared to 354 minutes for all-comers discharged from the ED during the study period. 28% of patients had a previous ED visit within 7 days of the index visit, and an additional 17% had a visit in the preceding 30 days. The ED care team indicated ‘Yes’ for RAAC referral from the ED for 66% of patients, for a mean of 4.3 patients referred per day during the study period. Multivariable analysis showed that all substances (except cannabis) correlated to a statistically significant increase in likelihood for indicating ‘Yes’ for RAAC referral from the ED (alcohol, stimulants, opioids, polysubstance; p < 0.05). Patients presenting to the ED with a chief complaint related to substance use were also more likely to be referred (p = 0.01). Conclusion: This retrospective chart review characterized substance-related presentations at a Canadian urban tertiary care ED. Approximately four patients per day would have been referred to an on-site RAAC had one been available. The RAAC model has been implemented in other Canadian hospitals, and collaborating with these sites to begin developing this service would be an important next step.

Introduction: A crucial component of a hospital's disaster plan is an efficient staff recall communication method. Many hospitals use a “calling tree” protocol to contact staff members and recall them to work. Alternative staff recall methods have been proposed and explored. Methods: An unannounced, multidisciplinary, randomized emergency department (ED) staff recall drill was conducted at night - when there is the greatest need for back-up personnel and staff is most difficult to reach. The drill was performed on December 14, 2017 at 4:00AM and involved ED staff members from three hospitals which are all part of the McGill University Health Centre (MUHC; Montreal, Quebec, Canada). Three tools were compared: manual phone tree, instant messaging application (IMA), and custom-made hospital Short Message Service (SMS) system. The key outcome measures were proportion of responses at 45 minutes and median response time. Results: One-hundred thirty-two participants were recruited. There were 44 participants in each group after randomization. In the manual phone tree group, 18 (41%) responded within 45 minutes. In the IMA group, 11 participants (25%) responded in the first 45 minutes. In the SMS group, seven participants responded in the first 45 minutes (16%). Manual phone tree was significantly better than SMS with an effect size of 25% (95% confidence interval for effect: 4.6% to 45.0%; P = .018). Conversely, there was no significant difference between manual phone tree and IMA with an effect size of 16% (95% confidence interval for effect: -5.7% to 38.0%; P = .17) There was a statistically significant difference in the median response time between the three groups with the phone tree group presenting the lowest median response time (8.5 minutes; range: 2.0 to 8.5 minutes; P = .000006). Conclusion: Both the phone tree and IMA groups had a significantly higher response rate than the SMS group. There was no significant difference between the proportion of responses at 45 minutes in the phone tree and the IMA arms. This study suggests that an IMA may be a viable alternative to the traditional phone tree method. Limitations of the study include volunteer bias and the fact that there was only one communication drill, which did not allow staff members randomized to the IMA and SMS groups to fully get familiar with the new staff recall methods.

Introduction: Burnout includes emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). Emergency Department (ED) staff have high levels of burnout that may be responsive to communication skills training. We surveyed ED staff perception of need and efficacy before and after an intervention using an established conflict resolution methodology. Methods: ED physicians, nurses and support staff were surveyed at two regional hospitals using the Maslach Burnout Inventory (MBI) and a communications questionnaire to establish the perceived need for communication skill training. Participants from one center were provided with a communications intervention (Crucial Conversations®, VitalSmarts®), and a refresher course 6-15 months later. The survey was then repeated at both sites and course participant feedback was elicited. Results: MBI results were high (mean EE = 25.25 (high > 25), 95% CI = 22.5-28; DP = 11.6 (high > 8), 95% CI = 10.1-13.2; PA = 35.85 (low <34), 95% CI = 34.3-37.4). Initially 82% of intervention and 77% of control site participants responded that “attending an educational session about ways to communicate better would help the participants at work”. Post intervention group responses to “The program will be helpful to me in communicating more effectively in my work environment” were: 75% “strongly agree” and 25% “agree”. No rating below “agree” was assigned by any of the participants. Participants preferred facilitated small group simulations and advocated for earlier career implementation. Conclusion: There was a perceived need for and impact from communication skills training for ED staff with high measured burnout. Training may be best implemented in small group simulated encounters and in health professional education curriculum or as part of work orientation.

Introduction: There is increasing evidence supporting ultrasonography for the determination of optimal chest compression location during cardiac arrest. Radiological studies have demonstrated that in up to 1/3 of patients the aortic root or outflow tract is being compressed during standard CPR. Out-of-hospital-cardiac-arrests (OHCA) could benefit from cardiac localization, undertaken with scaled-down ultrasound equipment by which the largest fluid filled structure in the chest (the heart) is identified to guide optimal compression location. We intend to evaluate 1) where the left ventricle is in supine patients, 2) the accuracy and precision as well as 3) the feasibility and reliability of cardiac localization with a scaled down ultrasound device (bladder scanners). Methods: We are recruiting men and women over the age of 40. The scanning protocol involves using a bladder scanner on a 15-point grid over the subject's left chest and parasternal, midclavicular, and anterior axillary intercostal spaces 3-7. Detected volumes will be recorded, with the presumption that the intercostal space with the largest measured volume is centered over the heart. Echocardiography will then be used to confirm the bladder scanner accuracy and to better describe the patient's internal chest anatomy. Having assessed procedural feasibility on 3 pilot subjects, we are now recruiting 100 participants, with planned interim analysis at 50 participants for sample size reassessment. Maximal volume location frequencies from the echocardiograms will be described and assessed for variation utilizing the goodness-of-fit test. The proportion of agreement across the two modalities regarding the maximal volume location will also be examined. Results: Among the 3 volunteers (pilot study), the scanner identified fluid in 4-8 of 15 intercostal spaces. In each of the three pilot study patients, the maximal volume identified by the bladder scanner was found to be at the parasternal location of the 6th intercostal space. This was also the location of the mid left ventricular diameter on echocardiography. Conclusion: Our literature review and pilot study data support the premise that lay persons and emergency medical personnel may improve compressions (and thus outcomes) during OHCA by using a scaled-down ultrasound to identify the location of optimal compression. We are currently enrolling patients in our study.

Introduction: During the one-year CCFP-EM program, residents rotate through different teaching sites. The purpose of this project is to investigate differences in procedural skills acquisition between these sites, which will help identify the effectiveness of each setting for teaching procedural skills amongst EM trainees. Methods: Over a two year period, residents enrolled in a CCFP-EM residency training program were asked to log their procedures and the sites where they were performed. The cumulative data was analyzed to show the number and types of procedures performed at each site. Results: A total of 477 procedures were logged over two years, with 198 procedures performed at urban tertiary emergency departments (EDs), 116 at community EDs, 87 at intensive care units (ICUs), 37 at urgent care centre, 24 in clinics, and 15 at other settings. Overall, 48 point of care ultrasounds, 75 vascular access procedures, 99 reduction/casting, 48 lumbar punctures, 29 procedural sedations, 125 minor surgical procedures, and 32 other procedures were performed. The majority of procedures were performed at the tertiary care urban ED, followed closely by community ED setting. The only exception was vascular access, which was performed most commonly in ICU settings. Conclusion: Our urban tertiary care ED setting provided the most learning opportunity for procedural skill acquisition, suggesting that having maximized time allocated in this setting is essential for EM learners to acquire procedural skills. One exception is that EM learners gain more vascular access training in ICUs.

Introduction: Pulse oximetry is a standard component of Emergency Department (ED) patient monitoring. Pulse oximetry measures peripheral capillary oxygen saturation (SpO2) levels and can be used to monitor cardiorespiratory conditions. The normal SpO2 level for adults is approximately 96%. Oxygen saturations of <92% are considered problematic and levels <90% may indicate cardiorespiratory disease. However, low oxygen saturations are often seen in elderly patients with comorbidities. This research investigated the significance of hypoxia in asymptomatic older ED patients with no apparent acute illness. Methods: ED patients >75 years with a documented room air pulse oximetry reading <92% were eligible. Exclusion criteria included dyspnea, chest pain, SBP <100mmHg, HR >120 or <50; sustained tachypnea (RR > 20); acute cardiopulmonary conditions, delirium or acutely altered mentation. Eligible patients were separated into two groups: 1) Sustained hypoxia: two or more SpO2 readings <92% 2) Unsustained hypoxia: one SpO2 reading <92%. 30-day adverse events were tracked using a Sunrise Emergency Care record review. Adverse outcomes investigated included death, MI, CHF, PE, cardioversion, ICU admission, intubation, ED revisit or re-hospitalization. Patient characteristics studied were age, sex, arrival mode, triage complaint, CTAS level, pulse, BP, RR, weight, residence (independent, assisted living, facility), comorbidities, PHN, referral, disposition, and test results (CXR, troponin, ECG, CT). Follow-up phone calls were completed after 30 days to assess patient status and confirm ED revisit. Results: A total of 876 ED patients >75 years were screened and 30-day follow-up data was analyzed for 34 enrolled patients. The sustained hypoxia group (n = 23) showed higher rates of 30-day adverse outcomes of death, ED re-visitation, MI, CHF, a severe episode of COPD, PE and ICU stays compared to the unsustained hypoxia group (n = 11). Administrative data of 31,095 patients >75 years from four Calgary EDs in 2017 was also analyzed and 7,771 (20%) were hypoxic at triage (SpO2 <92%). Adverse outcomes and mortality were significant in discharged hypoxic patients (especially if SpO2 <90%). Conclusion: ED re-visits, cardiorespiratory complications, and mortality were significant in discharged sustained hypoxic patients, especially if O2 sat <90%. Pulse oximetry assessment of oxygen saturation in seniors’ care facilities and physicians’ offices may be important in screening for future adverse health outcomes in elderly patients.

Introduction: Renal colic is a common presentation which exerts a significant burden on healthcare infrastructure. A significant proportion of patients managed with observation may return to the Emergency Department (ED) prior to spontaneous passage due to inadequate analgesia. It is unclear whether early urologist consultation would limit the burden of renal stones by reducing returns to the ED. We wished to determine whether urologist referral from the ED department is associated with fewer returns to the ED with renal colic. Methods: We conducted a retrospective chart review using RECORD methodology of consecutive patients diagnosed with CT-confirmed, ureteric or renal calculi in our ED over a two-year period. Disposition was categorized as either hospital admission, outpatient urologist referral, follow up with primary care, or no follow up. The primary outcome was the 30-day ED re-presentation for renal colic. Multivariate logistic regression was used to identify predictors for ED-return. Results: In total, 232 patients met our inclusion criteria. Urgent or outpatient urologist referral was not associated with a significantly lower ED return rate when compared to patients with no follow-up. Surprisingly, urologic intervention and stent placement were both independent predictors for ED return (OR: 2.03; 95% CI: (1.06-3.88); p:0.03) and (OR:2.08; 95% CI: (1.07-4.05). Conclusion: A significant proportion of patients who underwent urologist-led intervention returned to the ED with renal colic. Further study may help clarify the role of early urologist referral for renal calculi, as this may not reduce ED return rates when compared to conservative management.

Introduction: Mental health and addiction presentations are on the increase in Canadian Emergency Departments (EDs) and are placing strains on existing resources. The purpose of this study is to examine practice variations and opportunities for improved mental health (MH) consultation practices across four adult EDs. Methods: We conducted a retrospective analysis of administrative data from Alberta Health Services (AHS) at urban Calgary Zone EDs from 2015 to 2018 regarding MH consults requested and patients admitted to inpatient psych. Individual MD and overall referral rates as well as admission rates for patients consulted to MH were considered. Time of day and patient ETOH level were also examined as potential influencing factors. CEDIS codes were used to identify MH complaints. Results: 73,536 MH related visits were included, 29,228 received a MH consult with 10,648 admitted to an inpatient MH unit (36.4%). The admission rate among consults requested varied considerably among the 200 MDs who evaluated more than 50 patients with MH complaints; median 35.9%, IQR – 25.0 to 47.5. The average consultation rate for ETOH positive patients was 28.4% median 26.35%, IQR – 21.2 to 35.0% During regular working hours (08:00-17:00), there were 33,599 MH visits, 15,035 received a psych consult with 5,976 admitted to an inpatient MH unit. The admission rate among consults was 39.8%. For the remaining hours(17:01-07:59) there were 39,939 MH visits, 14,191 received a psych consult with 4,672 admitted to an inpatient MH unit. The admission rate among consults was 32.9%. Conclusion: Varying MD thresholds for MH consultation are reflected in a wide range of admission rates among patients consulted for MH evaluation in the ED. ETOH and timing of presentation are factors which modulate the likelihood of admission. There may be opportunities to improve MH referrals from the ED by providing consultation feedback to providers.

Introduction: While boarding of patients in the emergency department (ED) has been well documented and is carefully monitored, the time spent in emergency beds by patients waiting for Adult Protection (AP) placement is often relatively unnoticed, as they are not flagged as ‘admitted’. These patients have no emergency needs, yet consume considerable ED resources, often in excess of patients requiring emergency care. Staff familiarity with this issue may also bias them to premature diagnostic closure of patients as ‘placement problems’, risking misdiagnosis of active medical conditions. An observational study to retrospectively quantify the time spent in the ED by patients referred to AP services for urgent placement from the ED. Methods: A three-year audit of ED social work records of patients referred for AP. Results: For the period of October 1 2015-September 30, 2018, the ED social work service kept records of patients referred for AP from the ED. During this period, a total of 142 patients were referred to AP (40, 50, and 52 in each year respectively). There was an increase of 10 patients between 2015/16 and 2016/17 and two patients from 2016/17 to 2017/18. The overall length of stay for this subset of ED patients during this three-year period was alarmingly high, with an average length of stay of four days per patient (range 2.7 hours-18.5 days) compared to an average of all patients of 4.9 hours and admitted patients of 13.6 hours. Conclusion: Patients in the ED who are referred to AP services consume considerable ED resources, often requiring complete medical work-up, capacity assessments and close monitoring by multiple emergency personnel. This has been reported to cause considerable stress and friction between staff and consulting services. Furthermore, these patients are poorly served in a hectic, brightly lit, and noisy environment. The impact is often not fully appreciated due to ineffective capture by patient tracking systems.

Introduction: Patients with end-stage conditions require integrated physical, spiritual, psychological and social care. Despite efforts to provide comprehensive community care, those with severe symptoms often present to emergency departments (EDs) with palliative care (PC) needs. The objective of this study was to identify patients with end-stage diagnoses presenting to EDs, and to document and compare their PC needs. Methods: A four-month prospective cohort study was conducted in two Canadian EDs. Using a modified PC screening tool, volunteer emergency physicians identified adult patients with end-stage illnesses and documented their PC needs. This tool has the ability to classify patients as having met vs. unmet PC needs based on the documentation of risk factors. Research assistants documented demographic information, severity at presentation (Canadian Triage and Acuity Scale {CTAS}), disposition and revisits from an electronic repository. Bivariate comparisons between patients with met vs. unmet PC needs were completed. Results: Overall, 663 patients were enrolled, of which 78% (n = 518/663) were identified as having unmet PC needs according to the screening tool. Cancer was the most prevalent condition in each group (43% unmet needs, 37% met needs). There was no significant difference between the two groups in terms of age, sex or CTAS score. The unmet PC needs group was more likely to be admitted (68% vs. 50%; p = 0.0001) when compared to patients with PC needs assessed as being met. No significant difference was noted in terms of time to physician assessment or ED length of stay. The two groups did not significantly differ in the proportion of return visits within 30 days (34% vs. 32%) or the average number of return visits (3 vs. 2 visits). A higher proportion of patients with unmet PC needs made at least one visit to the ED in the 6 months prior to their index visit compared to patients with met PC needs (74% vs. 51%, p < 0.001); yet, the average number of ED visits was similar between the groups (3 visits). Conclusion: This study revealed that patients with end-stage diagnoses, especially cancer, commonly have unmet PC needs. They are also more likely to present to the ED and to require hospitalization than patients in whom PC needs have been met. Further investigations into their clinical profile and health care utilization may clarify the impact of their unmet PC needs on the healthcare system.

Introduction: While consultation is a common and important aspect of emergency department (ED) care, a previous systematic review identified significant utilization and process variation across ED's. The aim of this review update was to examine the proportion of the patients undergoing consultation in the ED among recent studies. Methods: Eight primary literature databases and the grey literature were searched. Studies published from 2007 to 2018 focusing on all-comers to the ED and reporting a consultation-related outcome were included. Disease- and specialty-specific studies were not eligible. Two independent reviewers screened studies for relevance, inclusion, quality assessment, and data extraction. Disagreements were resolved through consensus. Means, medians and interquartile ranges are reported. Wilcoxon-rank sum test and one-way ANOVA were used to identify differences between groups, as appropriate. Results: A total of 2632 unique citations and 49 studies from the grey literature were screened, of which 29 primary studies were included. Fifteen studies reported on the proportion of ED patients undergoing consultation, involving EDs in the Middle East (n = 4), North America (n = 4), Asia (n = 4), and Europe (n = 3). Overall, the proportion of patients receiving consultation ranged from 7% to 78% (median: 26%; IQR: 20%, 38%). There were no differences in the proportions of consulted patients based on country of origin. Ten studies were conducted prior to 2013, while five studies recruited patients during and after 2013. The mean proportion of consulted patients was lower for post-2012 studies compared to pre-2012 studies (mean: 18% vs. 36%; p = 0.0048). The proportion of consulted patients admitted to hospital ranged considerably between the 14 reporting studies (median: 56%; IQR: 49%, 76%). No differences in the proportion of admitted patients undergoing a consult were identified based on country of origin or year of recruitment for the study. Conclusion: Although consultation utilization appears to be decreasing overall, there is considerable practice variation in EDs around the world. These differences may result from variation in patient acuity, case-load, staffing levels, institutional and health-system organization, and medical training and future research should explore reasons for these differences.

Introduction: Renal colic is one of the most common presentations to the emergency department (ED), and often requires complex interdisciplinary collaboration between emergency physicians and urology surgeons. Previous literature has shown that adoption of interdisciplinary rapid referral clinics can improve both timeliness of care and patient outcomes. However, these Acute Care Surgery models have not yet been commonly adopted for urology care in the ED. Methods: In July 2016, we adopted the intervention of an Acute Care Urology (ACU) model through the creation of a rapid referral clinic dedicated to ED patient referrals, the addition of an ACU surgeon, and enhanced use of daytime OR blocks. We conducted a manual chart review of 579 patients presenting to the ED with a complaint of renal colic. Patient data was collected in two separate time periods to analyze trends before implementation of the ACU model (pre-intervention, September - November 2015), to examine the model's impact (post-intervention, September - November 2016). Secondary methods of evaluation included a survey of 20 ED physicians to capture subjective feedback through Likert scale data. Results: Of the evaluated 579 patients with a complaint of renal colic,194 patients were discharged from ED with an diagnosis of obstructing kidney stone and were referred to urology for outpatient care. The ED-to-clinic time was significantly lower for those in the ACU model (p <0.001). The mean time to clinic was 15.76 days (SD = 15.47, range 1-93) pre-intervention versus 4.17 days (SD = 2.33, range = 1-12) post-intervention. Furthermore, the ACU clinic allowed significantly more patients to be referred for outpatient care (p = 0.0004). There was also higher likelihood that patients would successfully obtain an appointment following referral (p = 0.0055). Decreasing trends were shown in mean ED wait time, in addition to time from assessment to procedure. Results of the qualitative survey were overwhelmingly positive. All 20 surveyed ED physicians were more confident that outpatients would be seen in a timely manner (85% strongly agree, 15% agree). Qualitative feedback included the belief that follow-up is more accessible, that ED physicians are less likely to page the on-call urologist, and that they are able to discharge patients sooner. Conclusion: The ACU model for patients with renal colic may be beneficial in reducing ED-to-clinic time, ensuring proper follow-up after ED diagnosis, and improving patient care within the ED.

Introduction: Benign headache (BHA) management varies across emergency departments (EDs). This study documented current BHA management by Alberta emergency physicians (EP) in order to develop a provincial intervention to improve standardized practice. Methods: A convenience sample of Alberta EPs completed an online survey exploring their ED BHA management practices. Results are expressed as proportions. Results: A total of 73 EPs (73/192; 38%) who were mostly male (63%) and practiced emergency medicine for at least 15 years (51%) responded. EPs reported routine ED orders for metoclopramide (97%), ketorolac (90%) and IV fluids (85%) for patients with BHA showing no signs of pathological headache. For moderate-severe BHA's that did not improve with routine treatment, preferences were: IV narcotic (58%), IV dexamethasone (44%), and IV/IM dihydroergotamine (27%). Typically, EPs reported not ordering investigations for moderate-severe BHA presentations (88%); however, for those not improving the most common investigation was computed tomography (CT; 47%). CT ordering was associated with the following clinical scenarios: 1) not responding to traditional therapy and consulted to specialist (64%); 2) not responding to traditional therapy and being admitted (64%); 3) first presentation and afebrile (19%); 4) severe pain (11%); and 5) responding to traditional therapy and febrile (11%). One-quarter of EPs (27%) believed their patients usually or frequently expected a CT. Most EPs (60%) reported being completely or mostly comfortable discussing CT risks. Only 44% reported always or usually discussing risks prior to ordering. EPs reported that they were most frequently prevented from discussing risks because the patient was critically ill (42%) or because they believed explaining risks would not alter patient expectations (21%). These concerns were mirrored in the barriers EPs anticipated to limiting imaging, specifically the fear of missing a severe condition (62%), and patient expectation/request for imaging (48%). Conclusion: Self-reported treatment preferences for uncomplicated BHAs appear to be relatively consistent. Chart reviews could help assessing the reliability of self-reported BHA management practices. Perceived patient expectation appears to be an important influence on EP imaging ordering. Studies examining the communication between EPs and their patients are needed to explore how these expectations and perceived expectations are negotiated in the ED.

Introduction: Efforts to engage patients in research when presenting to emergency departments (EDs) have explored the utility of online tools; for example, through QR-based applications. It is unclear whether these are effective strategies for engaging patients in research activities while saving costs of in-person surveys. This study evaluated whether patients would participate in QR codes or short URL-linked surveys available in EDs across Alberta. Methods: A patient waiting room poster was developed as part of a stepped-wedge randomized controlled trial. The waiting room poster was introduced in 15 urban and regional Alberta EDs with a median annual volume of approximately 60,000. A QR-code and short URL were placed on the poster inviting patients to participate in an online survey and evaluate the poster's usefulness and acceptability. Additionally, written discharge instructions, which were part of the intervention materials, were distributed with QR-code and short URL link to surveys for patients to share their ED care experience. Patients were not prompted by any staff or research personnel to encourage use of the QR codes or the short URLs; however, a survey was conducted with ED waiting room patients in 3 urban EDs to ascertain whether they had downloaded a QR reader on their devices and the frequency of use of these applications. Results: Given the stepped-wedge nature of the study, these materials were available for a total of approximately 123 months (3 sites for 13 months, 4 sites for 10 months, 4 sites for 7 months, and 4 sites for 4 months). Over the study period, 15 patients accessed and completed the online survey linked to the QR code or the short URL placed on the posters. No patients completed the online surveys linked to the QR code or the short URL placed on the discharge instructions. The in-person survey conducted within the ED waiting room identified that 34% of respondents had a QR code reader downloaded on their phone (108/316). Of those with a QR reader, 33% reported using the reader at least once within the last 6 months. Conclusion: In this study, few patients downloaded QR readers on their electronic devices while in the ED waiting room. Without prompting, this appears to be an ineffective strategy for engaging patients in emergency medicine research. Other engagement strategies optimizing human resource investment are urgently needed to effectively conduct research in EDs.

Introduction: Variation in image ordering exists across Alberta emergency departments (EDs). Evidence-based, pocket-sized knowledge dissemination tools were developed for two conditions (acute asthma [AA] and benign headache [BHA]) for which imaging (chest x-ray [CXR] and computed tomography [CT], respectively) has limited utility. This study explored tool acceptability among ED patients and emergency physicians (EPs). Methods: Tool feedback was provided by EPs, via online survey, and adult patients with AA and BHA via in-person survey. EPs qualitative interviews further explored communication tools. Preliminary descriptive analyses of survey responses and content analysis of interview data were conducted. Results: Overall, 55 EPs (55/192; 29%) and 38 consecutive patients participated in the AA study; 73 EPs (73/192; 38%) and 160 patients participated in the BHA study. In both studies, approximately 50% of EPs felt comfortable using the tool; however, they suggested including radiation risk details and imaging indications and removing references to imaging variation and health system cost. In the BHA study, EPs opposed the four Choosing Wisely® campaign questions fearing they would increase imaging expectations. In both conditions, most patients ( >90%) understood the content and 68% felt the information applied to them. Less than half (AA:45%; BHA: 38%) agreed that they now knew more about when a patient should have imaging workup done. Following tool review, 71% of AA and 50% of BHA patients stated they would discuss their imaging needs with their ED care provider today or during a future presentation. Both patient groups suggested including: additional imaging details (i.e., indications, risk, clinical utility), removing imaging overuse references, and including instructions that encourage patients to ask their EP questions. EP interviews (n = 12) identified preferences for personalized and interactive tools. Tensions were perceived around ED time pressure as well as remuneration schemes that fail to prioritize patient conversation. Tool centralization, easy access, and connection with outpatient support were also key themes. Conclusion: Both patients and EPs provided valuable information on how to improve ED knowledge dissemination tools, using two chronic conditions to demonstrate how these changes would improve tool utility. Implementing these recommendations, and considering preferences of EPs and patients, may improve future tool uptake and impact.

Introduction: Quality improvement and patient safety (QIPS) activities in healthcare have become increasingly important, but it is unclear what the current national landscape is with regards to how individual EM departments are supporting QIPS activities and evaluating their success and sustainability. We sought to assess how Canadian medical school EM departments/divisions and major Canadian teaching hospitals approach QIPS programs and efforts, with regards to training, available infrastructure, education, scholarly activities, and perceived needs. Methods: We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee, including a)formal training/skill capacity; b)operational infrastructure; c)educational activities; d)academic and scholarship, and e)perceived gaps and needs. Surveys were pilot-tested and revised by authors. “Survey 1” (21 questions) was sent by email to all 17 Canadian medical school affiliated EM Department Chairs and Academic Hospitals Department Chiefs; “Survey 2” (33 questions) to 11 identified local QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey. We present descriptive statistics including proportions, means, medians and ranges where appropriate. Results: 22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. 45% of respondents described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per center ranging from 1-10 over the past 5 years. A minority of participants reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%). Conclusion: This environmental scan provides a snapshot of QIPS activities in EM across academic centers in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.