Introduction: Pulmonary embolism (PE) is a potentially life-threatening condition that is in the differential diagnosis of many emergency department (ED) presentations. However, no diagnostic code for suspected PE exists. Thus, identifying the population of patients undergoing PE workup from administrative data for use as a denominator in clinical research and quality improvement can be difficult. To overcome this, we used standardized triage complaint codes and investigations to develop search algorithms useful to identify patients undergoing PE workup from an administrative dataset. Our objective was to quantify the sensitivity, specificity, and case yield of these search algorithms in order to identify a superior search strategy. Methods: Hospital administrative data for adult patients (age ≥18 years), which included standardized triage complaint codes and ICD-10 diagnostic codes for PE, were obtained from four urban EDs between July 2013 to January 2015. Standardized triage complaint codes were evaluated for the proportion of patients diagnosed with PE. Combinations of high-yield presenting complaints, in combination with D-dimer testing or imaging orders, were evaluated for sensitivity, specificity, and predictive values for PE. Results: Of 479,937 patients presenting with 174 different complaints, 1,048 were diagnosed with PE. The best-performing search strategy was the combination of standardized CEDIS complaints of Cardiac Pain, Chest Pain (Cardiac Features), Chest Pain (Non-Cardiac Features), Shortness of Breath, Syncope/Pre-syncope, Hemoptysis, and Unilateral Swollen Limb/Pain, along with with D-dimer testing and/or CTPA, or V/Q scan. This combination captured 808 PE diagnoses for a sensitivity of 77.1% (95%CI 74.4-79.5%) and specificity of 86.8% (95%CI 86.7-86.6%). Conclusion: We identified a high-yield combination of presenting complaints and test ordering that can be used to define an ED population with suspected PE. This population of patients can be used as a denominator in research or quality improvement work that evaluates the utilization of diagnostic testing for PE.

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

Introduction: Compared to pseudo-pulseless electrical activity (PEA with myocardial contractions present), true PEA is hypothesized to carry a poorer prognosis and to show bradycardia and a wide QRS complex on ECG. Our objective was to study the predictive potential of ECG characteristics on survival to hospital discharge (SHD) for out-of-hospital cardiac arrest (OHCA) patients with PEA initial rhythm. Methods: We studied a cohort of OHCA patients prospectively enrolled between Sept. 2007 and Oct. 2009 at the Ottawa/OPALS site (13 cities, 7 EMS, and 6 Fire services) of the ROC PRIMED study. We included adult (≥ 18) non-traumatic OHCA with PEA initial rhythm where resuscitation was attempted, and for which ECG characteristics were available. We measured mean heart rate (HR), mean QRS interval, and presence of P waves (each with kappa agreement) using the first six QRS complex available. We report patient and system characteristics using descriptive statistics and determined the impact of ECG characteristics (HR, QRS width, P waves) on return of spontaneous circulation (ROSC) and SHD using multivariate regression analysis. Results: Demographics of 332 included cases were: mean age 71.7; male 58.4%; home residence 76.5%; bystander witnessed 56.3%; bystander CPR 28.5%; interval from dispatch to paramedic arrival 6min:24sec; ROSC at ED arrival 26.5%; SHD 5.4%. Survivors had higher mean HR (66.1 vs. 52.0 bpm, p=0.83; kappa=0.69) and shorter mean QRS intervals (108.3 vs. 129.6 ms, p=0.01; kappa=0.74) compared to non-survivors. Presence of p waves could not reliably be ascertained (kappa=0.35). Predictors of ROSC were: ALS paramedic on scene (AdjOR=8.90, 95%CI 1.11-71.41; p=0.04), successful intubation (AdjOR=3.35, 1.75-6.39; p=0.0002), and use of atropine (AdjOR=0.27, 0.14 - 0.50; p<0.0001). Predictors of survival were: location of arrest (AdjOR=1.49, 1.11 - 1.99; p=0.007), and use of atropine (AdjOR=0.06, 0.02-0.22; p<0.0001). Despite various cutoff explorations, ECG characteristics were not predictive of ROSC or survival in multivariate analyses. Survivors had HR as low as 6 bpm and QRS as wide as 357 ms. Conclusion: Early ECG characteristics could not predict ROSC or SHD in a population of OHCA PEA victims, and should not be used to terminate resuscitation efforts. Atropine administration was consistently associated with decreased likelihood of ROSC and survival.

Introduction: An undefined yet potentially significant risk for Emergency Medical Services (EMS) systems are patients who access 911 with an ambulance response who are not transported to hospital (non-transport). Our objective was to determine the prevalence and associated characteristics of non-transport and potentially clinically adverse non-transports in Nova Scotia. Methods: We conducted a secondary analysis of pooled cross-sectional, population-based administrative data in a provincial EMS system that provides care to 920,000 residents. Electronic patient care record (ePCR) data was retrospectively analyzed for one calendar year (2014). The dependent variables were non-transport status and potentially adverse non-transport status. Potentially adverse non-transports were defined as a repeat call within 48 hours for a related complaint with the outcome of transport or death. Independent variables include patient characteristics, (age, sex, vitals and paramedic clinical impression), operational (crew type and response code) and environmental (time, date, and location). For both objectives we determined the prevalence of the outcome of interest, and associated characteristics. Results: There were 74,471 EMS responses between January to December 2014, 18.9% (n=14, 094/74,471) resulted in a non-transport. The characteristics most associated with non-transport are: age, paramedic clinical impressions, number of co-morbidities, response mode, and incident location type. As age decreased, the likelihood of non-transport increased. Younger non-transported patients (0-15 years old) (OR 2.2, 99.9% CI 1.9-2.5) are more likely to have non-transport. Relative to other paramedic clinical impressions, glycemic issues (OR 4.8; 99.9% CI 3.9-5.7) and wellness checks (OR 6.5; 99.9% CI 5.7-7.3) are more likely to have a non-transport. Non-transports are more likely at a detention facility (OR 4.1; 99.9% CI 3.2-5.1) or a roadway (OR 2.4; 99.9% CI 2.1-2.8). 5.6% (n=798/14094) of non-transport patients were classified as a potentially adverse non-transport. Conclusion: This study demonstrated that a significant portion of patients (18.9%) had a non-transport outcome, but only a small percentage (5.6%) were considered potentially adverse. The results of this study provide timely information to policy makers and healthcare practitioners on the scope of this issue, and suggest potential directions for future study and clinical decision making.

Introduction: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on first responders, Emergency Medical Services (EMS) and local Emergency Departments. Literature concerning these events is minimal and mostly consists of media reports. Recognizing the lack of epidemiologic data, we sought to accurately determine the patterns and frequency of injuries and illnesses that occur at OCRs, the treatments required, and what proportion require further medical care or transfer to hospital. Methods: Data were extracted from medical charts completed for all patients presenting to the on-site medical team at OCR events across Canada from May to August, 2015. Frequency and patterns of injuries and illnesses were determined as well as treatments and disposition. There were 45 285 OCR participants in 8 events. There were 572 total patient contacts and 557 patients were included in the study. 15 patients were excluded because they were not race participants. Results: Less than 2% of participants at any event required on-site medical care. 11 patients (1.97%) required transfer to hospital by EMS. The majority of injuries were musculoskeletal in nature (74.71%). 495 patients (88.87%) returned to the event with no need for further medical care. The majority of treatments could be provided with first aid training and basic medical equipment. Conclusion: Injury and illness rates at this series of OCRs was similar to other mass gathering events. Injuries were mostly musculoskeletal in nature and required minor treatment. Having a medical team on site likely reduced local hospital and EMS volume from these events. This study raises the question of whether having a physician on site at OCRs could significantly reduce the number of patients advised to seek further medical care or the number of ambulance transfers. Prospective research is needed in order to develop plans for more appropriate resources, safety protocols, and medical staffing, thereby improving patient care and reducing the burden on local EMS and rural hospitals.

Introduction: Frail older adults experience an increased risk of a number of adverse health outcomes such as comorbidity, disability, dependency, institutionalization, falls, fractures, hospitalization, and mortality. Identification of frail adults is important. The objective of this study is to examine the association between frailty and use of health services (emergency, general practitioner, hospitalization) prior to and following a visit for a fracture in non-institutionalized seniors. Methods: This study is a population-based cohort build from the Quebec Integrated Chronic Disease Surveillance System, an innovative chronic disease surveillance system linking five health care administrative databases. Algorithms using data from this system are accurate and reliable for identifying fractures. The sample includes 179,734 seniors ≥ 65 years old, non-institutionalized in the year before the fracture. Their frailty status was measured using the elderly risk assessment index. Poisson regression models were used to compare use of health services (emergency, general practitioner, hospitalization) 1 year before and 1 year after a visit for a fracture (adjusting for age, sex, comorbidities, social deprivation, material deprivation and site of fracture). Results: Overall, preliminary results show that the use of health services increased significantly in the year following the fracture in frail non-institutionalized elderly vs the non-frail one (p < 0.05). Conclusion: This study suggests that frail seniors with a fracture require more health services after their incident fracture. Furthermore, using a frailty assessment index in health administrative databases can help identify seniors that are at high risk of needing more health services and, therefore, improve their care.

Introduction: Delirium is a dreadful complication in seniors’ acute care. Many studies are available on the incidence of delirium, however ED-induced delirium is far less studied. We aim to evaluate the incidence and impact of ED-induced delirium among older non-delirious admitted ED patients who have prolonged ED stays (≥ 8 hours). Methods: This prospective INDEED study phase 1 included patients recruited from 4 Canadian EDs. Inclusion criteria: 1) Patients aged 65 and over; 2) ED stay ≥ 8 hours; 3) Patient is admitted to the hospital; 4) Patient is non-delirious upon arrival and at the end of the first 8 hours; 5) Independent or semi-independent patient. Eligible patients were assessed by a research assistant after an 8 hour exposition to the ED and evaluated twice a day up to 24h after ward admission. Patients’ functional and cognitive status were assessed using validated OARS and TICS-m tools. The Confusion Assessment Method was used to detect incident delirium. Hospital length of stays (LOS) were obtained. Univariate and multivariate analyses were conducted to evaluate outcomes. Results: Of the 380 patients prospectively followed, mean age was 76.5 (± 8.9), male represent 50% and 16.5% very old seniors (> 85 y.o.). The overall incidence of ED-induced delirium was 8.4%. Distribution by the 4 sites was: 10%, 13.8%, 5.5% & 13.4%. The mean ED LOS varied from 29 to 48 hours. The mean hospital LOS was increase by 6.1 days in the delirious patients compared to non-delirious patient (p<0.05). Increase mean hospital LOS distribution by site was by: 6.9, 8.5, 4.3 and 5.2 days for the ED-induced delirium patients. Conclusion: ED-induced delirium was recorded in nearly one senior out of ten after a minimal 8 hour exposure in the ED environment. An episode of delirium increases hospital LOS by about a week and therefore could contribute to ED overcrowding.

Introduction: Delirium is a common medical complication among seniors in hospital setting. In the emergency department (ED), its prevalence varies between 7 & 14%. Delirium is associated with increased mortality & longer hospital stay. This condition is also associated with functional & cognitive decline in hospitalized seniors and higher risk of institutionalization up to 2 years after their discharge. However, no data is currently available for ED patients. The aim of this study was to evaluate the association between ED-induced delirium and functional & cognitive decline in seniors at 60 days. Methods: This study is part of the Incidence and Impact measurement of Delirium Induced by ED-Stay (INDEED) study, an ongoing multicenter prospective cohort study in 5 Quebec EDs. Patients were recruited after 8 hours in the ED and followed up to 24h after admission. A 60-day follow-up phone assessment was also conducted. Delirium was measured by the validated Confusion Assessment Method & the Delirium Index. Functional status was measured by the validated OARS. Cognitive status was measured using the validated TICS-M. Functional and cognitive decline were obtained by comparing the baseline and 60-days follow-up scores. Results: 380 seniors were recruited and 280 had 60-day follow-up data available. ED-induced delirium was 8.4% of seniors. There was a difference in mean functional decline among seniors with and without ED-induced delirium 2.95(1.23-4.67) vs 1.55(1.20-1.91, pwlicoxon= 0.05] Proportion of seniors showing a decline ≥2 points on the OARS was significantly higher In those with ED-induced delirium (65,0 % vs 40.18 %, p=0.03). Seniors with ED-induced delirium also showed a significant decline in mean TICS scores [3.31 (0,82-5.84) vs -0.01((-.071-0.75)), pwlicoxon =0.009]. There was no significant difference in the proportions of seniors showing a decline ≥ 3 OARS points between those with or without delirium (p=0.06). Conclusion: ED-induced delirium seems to be associated with poor functional and cognitive outcomes in older patients 60 days after discharge from the hospital. Further studies are required to confirm clinical importance ED-induced delirium delayed complication.

Introduction: Ultrasound-guided femoral nerve block (USFNB) is optimal for providing analgesia for patients with hip fractures, but is rarely performed. Time of the procedure was cited as a barrier in our previous survey. Methods: We conducted a knowledge-to-practice intervention that included a two-hour training session on USFNB, use of a block kit, and reminders to improve uptake of USFNB. We measured the time it took for trained EPs to complete the block during a 20 month period. Results: Of 36 EPs, 34 (94.4%) were not routinely performing USFNB at the beginning of the study, and 4 declined to participate, leaving 30 participants who received training. The 30 trained EPs performed 100 USFNB over the next 20 months (range 1 to 20 blocks per EP). The mean reduction in pain was -4.47 on a 10 point numeric rating scale. The median time to perform the blocks was 15.0 minutes (IQR, 10 to 20 minutes), and 90 % of blocks took less than 30 minutes. The most common reason given for not performing a block was excessive clinical load. Conclusion: Given that we included 88.2% of eligible EP’s and included the first time EP’s performed a USFNB, our estimates of time to perform USFNB block should generalize to other Canadian academic ED’s. Time to complete USFNB is in keeping with other commonly performed ED procedures and should not be a barrier to optimizing analgesia.

Introduction: Individual and institutional disparities in CT imaging rates for patients with head injuries have long been recognized, leading to the development of well-validated clinical decision rules designed to standardize clinical practice. To assess their impact on current practice, we sought to evaluate variation in CT imaging by emergency physicians for patients presenting with head injury across the province of Alberta. Methods: A unique data warehouse merging administrative, clinical, and imaging platforms for 11 Alberta emergency departments (EDs) was created. Unique identifiers were obtained for all emergency physicians who were included in this analysis if they evaluated in excess of ten ED patients presenting with a chief complaint of “head injury”. Patients with high triage acuity (CTAS 1) were excluded, as were patients who were admitted to hospital. Descriptive statistics were employed to describe variation between physicians and sites for a 24 month period from 2013-2015. Results: 311 emergency physicians treating 20,797 patient encounters for head injury were included. Overall a total of 8,245 head injury patients (40%) received one or more CT scans. Physician variation across the 11 sites ranged from 4% -100% of head injury patients receiving a CT. Within sites CT ordering between physicians varied from 9-fold (4% - 36%) at the lowest variation site, to more than 20-fold (4% - 90%) at the highest variation site. After removing the 5% lowest and highest ordering physicians, variation in ordering continued to range from 10% - 72%. No trends were observed across the two years examined. Conclusion: This is the largest study to date examining physician level variation in CT ordering practices for ED head injury patients. We have identified marked persistent practice variation despite the presence of well-validated clinical decision rules and a relatively low risk medicolegal environment. Variable risk tolerance and limited use of validated clinical decision rules are likely contributors making this area an ideal focus for targeted interventions to improve imaging appropriateness and reduce practice variation.

Introduction: Nova Scotia has a province wide reperfusion strategy for the treatment of patients presenting with acute ST-Elevation Myocardial Infarction (STEMI). Patients are referred for primary percutaneous coronary intervention (PPCI) if a first medical contact to device time can be achieved within 90 to 120 minutes; otherwise, fibrinolytic therapy is administered, as per guideline recommendations. Since 2011, Nova Scotian paramedics have been providing prehospital fibrinolysis (PHF) and prehospital catheterization (cath) lab activation for STEMI patients outside and within the PPCI catchment area, respectively. Patients who received fibrinolysis are transferred to a PCI facility if rescue PCI is required or if there are other indications for urgent intervention. This province wide approach is unique and the objective of this retrospective cohort study is to compare the impact of this approach on the primary outcome of 30-day mortality. Methods: For the study period, July 2011 to July 2013, STEMI patients who were diagnosed prehospital or in the ED who subsequently underwent reperfusion therapy were identified in the Emergency Health Services (EHS), Cardiovascular Information Systems (CVIS) and Cardiovascular Health Nova Scotia (CVHNS) databases. Baseline demographics and outcomes were then compared according to the treatment received: 1) PHF; 2) ED Fibrinolysis (EDF); 3) prehospital activated PPCI (EHS PPCI); and 4) ED activated PPCI (ED PPCI). Results: There were a total of 1107 STEMI patients identified during the study period, of whom 742 received lytic therapy (146 PHF; 596 EDF) and 332 underwent PPCI (202 EHS PPCI; 130 ED PPCI). Demographic variables were similar across the groups. The primary outcome of 30-day mortality was not significantly different across groups: 5 (3%) in PHF, 26 (4%) in EDF, 8 (4%) in EHS to PPCI and 2 (2%) in ED to PPCI. The number of rescue PCIs was 28 (19%) in PHF and 102 (17%) in EDF. Other outcomes (key timestamps) are pending. Conclusion: Our results show that the 30-day mortality was lowest for patients undergoing PPCI and slightly less for patients receiving pre-hospital fibrinolytic compared to those receiving ED fibrinolytic with no difference in the proportion requiring subsequent rescue PCI. The majority of patients in rural areas received EDF as opposed to PHF; pending results will show if this represents a delay in patient presentation after symptom onset.

Introduction: Following a protocol derived from the Canadian C-spine Rule (CCR), patients 65 years and older transported by ambulance after trauma require full spinal immobilisation. Immobilisation complicates the transport and the evaluation; potential side effects have been recognized. The aim of this study was to evaluate the effect of mechanism of trauma and age on the rate of cervical injury in a geriatric population. Methods: We conducted a retrospective observational study on patients 65 years and older transported by ambulance to a level-one trauma center from March 2008 to October 2013. The outcome was the rate of clinically important cervical spine injury (CICSI), defined as any fracture, dislocation or ligamentous injury needing treatment or specialised follow up. The rate was calculated in the geriatric population and in the subgroup of patients with minor trauma, defined as a fall from a standing height, a chair or a bed. We then looked at the rate of CICSI based on age to define a subgroup at lower risk of lesion. Results: We included 1221 patients with a mean age of 80 y.o. (SD = 8), 739 women (61%). CICSI was found in 53 patients (4.3%, 95% CI 3.2-5.4). This is similar to the rate found in patients 65 years and older in the NEXUS population (4.6%) and the CCR population (6.0%). The mechanism of injury was a minor trauma for 716 patients (59%). Of those, 24 patients (3.4%, 95% CI 2.1-4.7) had CICSI. The rate increased after 85 y.o in both the overall population (3.4% vs 6.4%) and the minor trauma subgroup (2.6% vs 4.4%). Conclusion: The subgroup of patients 65-84 y.o. with a minor trauma had the lower rate of cervical spine injury (2.6%). In a lot of prehospital systems, those patients are not systematically immobilised for transport. It will be interesting to review the files of all patients with CICSI to identify any possible case that would have been missed without the age criteria.

Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Among the domains assessed by the CIWA-Ar, tremor is the most objective indicator of withdrawal severity, however, the ability of clinicians to reliably quantify tremor is highly dependent on experience. The objective of this study was to prospectively validate an objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application. Methods: A prospective observational study of patients ≥18 years presenting to an academic emergency department in alcohol withdrawal was conducted from Oct 2014 to Aug 2015. Assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Accelerometer derived results were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 76 patients with 78 tremor recordings were included. Accelerometer derived tremor scores matched exactly with expert assessor scores in 36 (46.2%) cases, within 1 point for 73 (93.6%) cases and differed by ≥ 2 points in 5 (6.4%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘very good’ 0.92 (95% CI: 0.86, 0.99). Conclusion: iOS accelerometer based assessment of the tremor component of the CIWA-Ar score is reliable and has potential to more accurately assess the severity of patients in alcohol withdrawal. We anticipate this resource will be easily disseminated and will impact and improve the care of patients with alcohol withdrawal.

Introduction: Mental health concerns make up 5-10% of all adult presentations to Canadian emergency departments (ED). One challenge for the emergency physician (EP) is determining if a patient with a mental health concern has concomitant underlying medical illness. We defined “serious medical illness” (SMI) as a pathological condition that requires inpatient treatment on a medical or surgical ward. SMI undetected by emergency physicians in patients presenting with mental health concerns may result in adverse patient outcomes. The aim of this study was to determine the prevalence, timing, and etiology of undetected SMI in the ED among adult patients presenting with mental health concerns. Methods: A retrospective chart review was performed on all patients age 18 and older who presented to the ED at Victoria Hospital, London Health Sciences Centre between October 1, 2014 and April 30, 2015, who were subsequently referred to psychiatry by the EP. The primary outcome was the number of patients transferred to a medicine or surgery inpatient unit for treatment of their SMI within seven days of psychiatry admission from the ED. Results: 1,255 patients were referred to psychiatry during the study period. 803 patients were admitted and 452 were discharged. Of the admitted patients, 14/803 patients (1.7%) met our primary outcome. The mean age of patients in the SMI group (n=14) was 64 years. The mean age in the non-SMI group (n=1,241) was 38. In the SMI group, 3/14 patients died, 2/14 patients required an ICU admission, and 2/14 patients underwent a surgery for their missed SMI. The average length of psychiatry admission prior to transfer was 3.7 days. The average length of medical/surgical admission after transfer from psychiatry was 8.3 days. Undetected diagnoses included NSTEMI, serotonin syndrome, lithium toxicity, thoracic aortic aneurysm, gastrointestinal stromal tumour, forearm abscess, Parkinsonian crisis, and others. Conclusion: This chart review demonstrated a 1.7% rate of undetected serious medical illness in patients who presented to the ED with mental health concerns. Adverse outcomes included death, ICU admissions, and surgeries. This rate is similar to other studies on the topic. The SMI group tended to be older than the non-SMI group. This research may have implications on the appropriate workup and disposition of elderly patients presenting to the ED with mental health concerns.

Introduction: Of the domains assessed by the CIWA-Ar, tremor is the most objective, and reliable clinical symptom of alcohol withdrawal syndrome. Even so, anecdotal evidence suggests that the ability of health care workers to reliably rate tremor severity is highly variable, and there is no high quality, readily available training to teach this competency. Improper evaluation and interpretation of tremor may result in under or over treatment, posing serious risks to patient safety, prolonging emergency department (ED) length of stay, and increasing the likelihood of complications/hospital admission. The objective of this study was to prospectively compare tremor assessment scores assigned by nurses and clinical experts for patients with alcohol withdrawal syndrome in the ED. Methods: A prospective observational study was conducted for patients ≥18 years presenting to an academic ED in alcohol withdrawal from Oct 2014 to Aug 2015. Individual tremor assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Tremor severity scores assigned in real-time by the nurses were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 31 patients with 62 tremor recordings were included. Nurse-derived tremor scores matched exactly with expert assessor scores in 11 (17.7%) cases, within 1 point for 29 (46.8%) cases and differed by ≥ 2 points in 33 (53.3%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘fair’ 0.39 (95% CI: 0.25, 0.53). Conclusion: These results confirm the high variability in the assessment of alcohol withdrawal tremor by health care workers. Future research should focus on ways to improve the accuracy of tremor in alcohol withdrawal patients, and the development and implementation of an educational program to improve the individual competencies of clinical staff in the recognition and treatment of alcohol withdrawal in the ED.

Introduction: Injuries due to interactions with dogs (e.g. bites, collisions, etc) are an important public health concern from both a health and an economic perspective. The consequences of these injuries can be both physical (injury, pain, infection, disfiguration) and psychological. The purpose of this study is to understand the prevalence and characteristics of dog-related injuries among patients presenting to Alberta emergency departments (EDs). Further, this study describes the burden of these injuries on ED economic health care resources. Methods: This retrospective, administrative database cohort study utilised the National Ambulatory Care Reporting System (NACRS) to identify all visits made to Alberta EDs in fiscal years 2010/11 through 2014/15 for dog-related injuries. ED visits where the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) code “W54-Bitten or Struck by Dog” appeared in the first four diagnosis fields were captured. The Canadian Institute for Health Information costing model utilising the Comprehensive Ambulatory Classification System and Resource Intensity Weights was employed to calculate average unit health care costs for ED visits excluding physician fees. Data were analyzed using descriptive statistics. Results: During the 5 year study period, Albertans made 21,821 ED visits for dog-related injuries. The ED visit rate was highest in children under 2 years of age, namely 234 per 100,000 for males and 206 per 100,000 for females. ED visit rates were highest for patients residing in the northern health region of the province (220/100,000) compared to metropolitan areas (90/100,000 and 64/100,000 for Edmonton and Calgary zones respectively). One third of visits occurred in the summer months, with a greater proportion of visits occurring on the weekend (34.4%). The predominant areas of injury were wrist/hand/fingers (n=7756 visits; 35.5%) and head/face/neck (n=5152 visits; 23.6%). In 287 visits (1.3%), the patient was admitted to hospital. ED visit costs were highest for children 4 years of age and younger ($243.86/visit; p<0.001). Conclusion: Dog-related injuries result in a substantial number of ED visits and significant costs in Alberta. Understanding the characteristics of these injuries provides an opportunity for prevention, including strategies focussed on higher risk groups involving children and residents of rural areas.

Introduction: Emergency medicine by its nature requires shift-work that often follows an erratic and unpredictable pattern. Faced with this ongoing challenge we hypothesized that many ED physicians may have taken steps to minimize their personal sleep deprivation through the use of a pharmacological sleep aid (PSA). The extent and nature of PSA use in this population is not well studied. We sought to describe the use of PSAs amongst practicing ED physicians in a Canadian tertiary-care setting. We also hoped to determine the specific substances being used, their frequency and predictive factors contributing to their use. Methods: A cross-sectional descriptive web-based survey was sent via e-mail to all practicing staff emergency physicians within the Calgary zone of Alberta Health Services. Participation was entirely voluntary and all responses were anonymous. Descriptive statistics were used to assess frequencies and summary measures. Logistic regression was used to explore associations between key variables. Results: Of the 198 eligible ED physicians, 144 (73%) completed the survey. 132 (92%) felt that shift-work negatively affected their ability to sleep and 121(84%) had experienced insomnia at some point in their medical career. 96(67%) ED physicians had used a PSA at some time in their career and 82(57%) were currently using a PSA with any frequency. The most frequent sleep aids currently being used were non-benzodiazepine hypnotics (65%), alcohol (31%) and melatonin (27%). 66(46%) respondents required a prescription for their PSA and 37(56%) of those had obtained a prescription from an ED physician colleague. Physician self-reporting of experience with insomnia was strongly associated with prior use of any PSA (OR 4.0; 95% CI 1.6-10.0) and prior use of non-benzodiazepine hypnotics (OR 14.4; 95% CI 3.2-64.2) There was no statistically significant association between current use of a PSA and physician age, physician gender, number of night shifts worked per month or co-habitation with children. None of the physicians who responded felt that their use of a PSA adversely affected their ability to provide quality patient care. Conclusion: Pharmacological sleep aid use among Canadian ED physicians may be more common than previously assumed. This could have implications for physician wellbeing and performance.

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

Introduction: The older adult population is growing. The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a MT-HI on the functional and cognitive outcomes six months post injury of older adults who sustained a minor trauma. Methods: This multicenter prospective cohort study in eight sites included patients who were: aged 65 years or older, presenting to the emergency department (ED) within two weeks of injury with a chief complaint of a minor trauma, discharged within 48 hours, and independent for their basic activities of daily living prior to the ED visit. Participants underwent a baseline evaluation and a follow-up evaluation at six months post-injury. The main outcome was the functional decline measured with the Older Americans’ Resources and Services (OARS) scale six months after the trauma. Results: All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 without head injury. After six months, the functional decline was similar in both groups, 10.8% and 11.9% respectively (RR=0.79 [95% CI: 0.55-1.14]). The proportion of participants with mild cognitive disabilities was also similar, 21.7% and 22.8% respectively (RR=0.91 [95% CI: 0.71-1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR= 1.35 [95% CI: 0.71-2.59]), or with or without the presence of a mTBI as defined by the WHO criteria (RR= 0.90 [95% CI: 0.59-1.13]). Conclusion: This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population six months after injury.

Introduction: Recurrent admission to a hospital or trauma centre for separate incidents of traumatic injury is known as trauma recidivism. Although use of alcohol is a known risk factor for injury and associated with trauma recidivism, the scale of alcohol-related trauma recidivism has not been well described. The purpose of this review was to search the published literature for studies that evaluated the prevalence of alcohol use among trauma recidivists. Our primary objective was to determine the proportion of trauma recidivism related to alcohol use. The association between alcohol and trauma recidivism was evaluated as a secondary objective. Methods: Four electronic databases (MEDLINE, Embase, CINAHL, Web of Science) were searched from inception until December 2015 for all articles that might provide evidence on the proportion of trauma recidivism related to use of alcohol. After removal of duplicates, the search strategy yielded 2470 records for screening. Only primary studies that reported on repeated admissions to a hospital or trauma center for traumatic injuries specifically related to alcohol use were included. Descriptive statistics were used to assess study characteristics and the prevalence of trauma recidivism related to alcohol use. An aggregate weighted estimate of alcohol-related trauma recidivism was calculated. Results: A total of 12 studies met all inclusion criteria. Studies were published between 1989 and 2014. Overall, there were 3386 trauma recidivists among included studies. The proportion of trauma recidivists with evidence of alcohol use on admission ranged from 26.7% to 76.9% (median 46.4%). The aggregated sample produced a weighted estimate of 41.0% (1388/3386) for alcohol-related trauma recidivism. In four studies, the association between alcohol and trauma recidivism was examined; all four found a positive association between alcohol use and repeated admission for traumatic injury. Studies varied considerably in design, trauma populations, periods for evaluating recidivism, definitions for positive alcohol on admission, and methods used to determine alcohol use. Conclusion: Evidence from current literature suggests that 41.0% of trauma recidivism is related to use of alcohol. Due to methodological limitations among the studies included for review, this may underestimate the actual prevalence of alcohol-related trauma recidivism.