Introduction: Clinical simulations in are designed to evoke feelings of stress and uncertainty in order to mimic challenges that learners will face in the real world. When not managed properly, these sources of extraneous cognitive load cause a burden on working memory, leading to a hindered ability to acquire new information. The “Beat the Stress Fool” (BTSF) protocol is a performance-enhancing tool designed to reduce cognitive overload during acute care scenarios. It involves breathing exercises, positive self-talk, visualization, and deliberate articulations. This study aims to validate the BTSF protocol as a method for reducing cognitive load using both psychometric and physiologic measures. Methods: Data collection took place during the Queen's University “Nightmares-FM” course. This clinical simulation program involves team-based scenarios designed to teach the fundamentals of acute care to first-year family medicine residents. Participants were divided equally into experimental and control groups based on pre-existing cohorts. Participants completed a baseline state-trait anxiety inventory and a demographics survey. The experimental group was guided through the BTSF protocol prior to each of 16 simulations; in both groups, physiologic and psychometric cognitive load measurements were collected for the alternating team leader. Galvanic skin response (GSR) and heart rate (HR) were collected during a 15-second baseline and throughout each simulation using a Shimmer 3 GSR+ wearable sensor. Self-reported cognitive load was assessed after each scenario using the 9-point Paas scale. Results: The mean Paas scores for the BTSF group were significantly lower than the control group (6.2 vs 6.9, p < 0.05), indicating lower subjective cognitive load. GSR signal magnitude (p = 0.086), spike amplitude (p = 0.066), and spike density (p = 0.584) were also lower in the BTSF group. There was no difference in HR between groups. There was not a significant correlation between self-reported cognitive load and the normalized physiologic measures. Conclusion: The results demonstrate the effectiveness of the BTSF protocol in lowering the amount of perceived mental effort required to perform clinical simulation tasks. These findings were mirrored in the galvanic skin response signal, though our study was likely underpowered for significance. This is the first study to validate a proof-of-concept for the BTSF protocol in learners during simulated training.

Introduction: A critical component for successful implementation of any innovation is an organization's readiness for change. Competence by Design (CBD) is the Royal College's major change initiative to reform the training of medical specialists in Canada. The purpose of this study was to measure readiness to implement CBD among the 2019 launch disciplines. Methods: An online survey was distributed to program directors of the 2019 CBD launch disciplines one month prior to implementation. Questions were developed based on the R = MC2 framework for organizational readiness. They addressed program motivation to implement CBD, general capacity for change, and innovation-specific capacity. Questions related to motivation and general capacity were scored using a 5-point scale of agreement. Innovation-specific capacity was measured by asking participants whether they had completed 33 key pre-implementation tasks (yes/no) in preparation for CBD. Bivariate correlations were conducted to examine the relationship between motivation, general capacity and innovation specific capacity. Results: Survey response rate was 42% (n = 79). A positive correlation was found between all three domains of readiness (motivation and general capacity, r = 0.73, p < 0.01; motivation and innovation specific capacity, r = 0.52, p < 0.01; general capacity and innovation specific capacity, r = 0.47, p < 0.01). Most respondents agreed that successful launch of CBD was a priority (74%). Fewer felt that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). While most programs indicated that their leadership (94%) and faculty and residents (87%) were supportive of change, 42% did not have experience implementing large-scale innovation and 43% indicated concerns about adequate support staff. Programs had completed an average of 72% of pre-implementation tasks. No difference was found between disciplines (p = 0.11). Activities related to curriculum mapping, competence committees and programmatic assessment had been completed by >90% of programs, while <50% of programs had engaged off-service rotations. Conclusion: Measuring readiness for change aids in the identification of factors that promote or inhibit successful implementation. These results highlight several areas where programs struggle in preparation for CBD launch. Emergency medicine training programs can use this data to target additional implementation support and ongoing faculty development initiatives.

Introduction: Little is known about how Royal College emergency medicine (RCEM) residency programs are selecting their residents. This creates uncertainty regarding alignment between our current selection processes and known best practices and results in a process that is difficult to navigate for prospective candidates. We seek to describe the current selection processes of Canadian RCEM programs. Methods: An online survey was distributed to all RCEM program directors and assistant directors. The survey instrument included 22 questions consisting of both open-ended (free text) and closed-ended (Likert scale) elements. Questions sought qualitative and quantitative data from the following 6 domains; paper application, letters of reference, elective selection, interview, rank order, and selection process evaluation. Descriptive statistics were used. Results: We received responses from 13/14 programs for an aggregate response rate of 92.9%. A candidate's letter of reference was identified as the single most important item from the paper application (38.5%). Having a high level of familiarity with the applicant was considered to be the most important characteristic of a reference letter author (46.2%). Respondents found that providing a percentile rank of the applicant was useful when reviewing candidate reference letters. Once the interview stage is reached, 76.9% of programs stated that the interview was weighted at least as heavily as the paper application; 53.8% weighted the interview more heavily. Once final candidate scores are established for both the paper application and the interview, 100% of programs indicated that further adjustment is made to the rank order list. Only 1/13 programs reported ever having completed a formal evaluation of their selection process. Conclusion: The information gained from this study helps to characterize the landscape of the RCEM residency selection process. We identified significant heterogeneity between programs with respect to which application elements were most valued. Canadian emergency medicine residency programs should re-evaluate their selection processes to achieve improved consistency and better alignment with selection best practices.

Introduction: Mastery learning, which deconstructs a complex task into sequential sub-steps combined with deliberate practice to achieve each step in sequence, represents an important method to enhance simulation-based procedural skills training. However, the evidence to support the effectiveness of this theory to improve learning is lacking. This study compared mastery learning using deliberate practice with self-guided practice on skill performance of a rarely performed, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). Methods: In this multi-centre, randomized study at five North American emergency medicine (EM) residency training programs, we assigned 166 EM postgraduate trainees to either mastery learning and deliberate practice (ML + DP) or self-guided practice for BAC. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test) and after (post-test) each training session. The primary outcome was post-test skill performance using a 5-point global rating score (GRS). A secondary outcome, defined a priori, was performance time to complete the BAC skill (chronometry). Results: There was no significant difference in post-test BAC performance after ML + DP or self-guided practice. Performance scores improved for both groups by 13% from the pre-test to post-test (F (1,138) = 43, p < 0.001). Overall, time to complete the BAC improved significantly from pre-test (87.6 seconds) to posttest (54.1 seconds), (F, 1,149) = 122, p < 0.001). At post-test, the ML + DP group performed the skill 7.4 seconds faster than the self-guided practice group (F (1,150) = 6.77, p < 0.01). Conclusion: Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource intensive and its efficacy is not fully defined. In this study, MP + DP did not result in improved global performance; it did result in faster performance times, a relevant finding for time-sensitive procedures. These results are important for educators who seek to optimize technical skills training in a competency-based model of medical education. Our findings suggest that time-sensitive procedures might benefit from ML + DP teaching strategies to enhance time to procedural performance.

Introduction: In the emergency department (ED), high-acuity presentations encountered at low frequencies are associated with reduced staff comfort. Previous studies have shown that simulation can improve provider confidence with practical skills and management of presentations in various fields of medicine. The present study examined the effect of in situ simulation on interprofessional provider comfort with the identification and management of high-acuity low-frequency events in the ED. It further assessed the feasibility of implementing weekly simulation as an interprofessional education initiative in a high-volume ED. Methods: This was a retrospective pre-test post-test quasi-experimental design. Weekly in situ simulation events were facilitated by an interdisciplinary team in a high-volume ED in Hamilton, Ontario that sees an average of 185 patients per day. To date, 34 simulation events were held between January 18, 2019 and November 22, 2019, and included neonatal, paediatric and obstetric emergencies, and adult codes. There was an average of 20 patients presenting to the ED during these events. Events included a debrief, and typically lasted 60 minutes in total. Participants included individuals from various disciplines working on shift at the time of the event. Questionnaires were administered via email following the event, in which participants were asked to rank their comfort with emergency codes before and after the simulation using two 5-point Likert scales. The data from 39 questionnaires was analyzed. T-tests were used to analyze differences in self-reported comfort scores. Results: Questionnaire responders included nurses (41%), respiratory therapists (26%), resident physicians (10%), paramedics (3%), attending physicians (3%), students of various disciplines (10%) and other (7%). 38% of participants reported increases in comfort following simulation when compared to prior. Using the 5-point scale, the average reported score for comfort pre-simulation was 3.59 (95% CI 3.30–3.88), and the average post-simulation score was 3.97 (95% CI 3.76–4.19, p = 0.03). Conclusion: Our results demonstrate that weekly interprofessional in situ simulation is feasible in a high-volume ED, and significantly improves self-reported provider comfort with the identification and management of high-acuity, low-frequency events. This warrants the implementation of this simulation design to improve staff confidence and has implications for its potential role in improving team dynamics and patient safety.

Introduction: Assessment of point-of-care ultrasound (POCUS) competency has been reliant on practical, visual and written examinations performed 1-on-1 with an examiner. These tools attempt to assess competency through subjective ratings, checklists and multiple-choice questions that are labour intensive using surrogate measures. Eye-tracking has been used on a limited basis in various fields of medicine for training and assessment. This technology explores visual processing and holds great promise as a tool to monitor training progress towards the development of expertise. We hypothesize that eye-tracking may differentiate novices and experts as they progress to become competent in interpretation of POCUS images and provide an objective measure in assessment of competency. Methods: Medical students, residents and attending physicians working in an academic emergency department were recruited. Participants viewed a series of 16 ultrasound video clips in a POCUS protocol for Focused Assessment using Sonography in Trauma (FAST). The gaze pattern of the participants was recorded using a commercially available eye-tracking device. The primary outcome was the gaze parameters including total gaze time in the area of interest (AOI), average time to fixation on the AOI, number of fixations in the AOI and average duration of first fixation on the AOI. Secondary outcome was the accuracy on the interpretation of the FAST scan. Results: Four novices and eight experts completed this study. The total gaze time in the AOI (mean +/- SD) was 76.72 +/- 18.84s among experts vs 53.64 +/- 10.33s among novices (p = 0.048), average time to fixation on the AOI was 0.561 +/- 0.319s vs 1.048 +/- 0.280s (p = 0.027), number of fixations in the AOI was 158.9 +/- 29.0 vs 121.8 +/- 17.5 (p = 0.042) and average duration of first fixation was 0.444 +/- 0.119s vs 0.390 +/- 0.024s (p = 0.402). The accuracy of the answers was 79.7 +/- 14.1% vs 45.3 +/- 21.9% (p = 0.007). Conclusion: In this pilot study, eye tracking shows potential to differentiate between POCUS experts and novices by their gaze patterns. Gaze patterns captured by eye tracking may not necessarily translate to cognitive processing. However, it allows educators to visualise the thought processes of the learner by their gaze patterns and provide insight on how to guide them towards competency. Future studies are needed to further validate the metrics for competency in POCUS applications.

Introduction: Workplace based assessments (WBAs) are integral to emergency medicine residency training. However many biases undermine their validity, such as an assessor's personal inclination to rate learners leniently or stringently. Outlier assessors produce assessment data that may not reflect the learner's performance. Our emergency department introduced a new Daily Encounter Card (DEC) using entrustability scales in June 2018. Entrustability scales reflect the degree of supervision required for a given task, and are shown to improve assessment reliability and discrimination. It is unclear what effect they will have on assessor stringency/leniency – we hypothesize that they will reduce the number of outlier assessors. We propose a novel, simple method to identify outlying assessors in the setting of WBAs. We also examine the effect of transitioning from a norm-based assessment to an entrustability scale on the population of outlier assessors. Methods: This was a prospective pre-/post-implementation study, including all DECs completed between July 2017 and June 2019 at The Ottawa Hospital Emergency Department. For each phase, we identified outlier assessors as follows: 1. An assessor is a potential outlier if the mean of the scores they awarded was more than two standard deviations away from the mean score of all completed assessments. 2. For each assessor identified in step 1, their learners’ assessment scores were compared to the overall mean of all learners. This ensures that the assessor was not simply awarding outlying scores due to working with outlier learners. Results: 3927 and 3860 assessments were completed by 99 and 116 assessors in the pre- and post-implementation phases respectively. We identified 9 vs 5 outlier assessors (p = 0.16) in the pre- and post-implementation phases. Of these, 6 vs 0 (p = 0.01) were stringent, while 3 vs 5 (p = 0.67) were lenient. One assessor was identified as an outlier (lenient) in both phases. Conclusion: Our proposed method successfully identified outlier assessors, and could be used to identify assessors who might benefit from targeted coaching and feedback on their assessments. The transition to an entrustability scale resulted in a non-significant trend towards fewer outlier assessors. Further work is needed to identify ways to mitigate the effects of rater cognitive biases.

Introduction: It is unclear whether anticoagulant or antiplatelet medications increase the risk for intracranial bleeding in older adults after a fall. Our aim was to report the incidence of intracranial bleeding among older adults presenting to the emergency department (ED) with a fall, among patients taking anticoagulants, antiplatelet medications, both medications and neither medication. Methods: This was a systematic review and meta-analysis, PROSPERO reference CRD42019122626. Medline, EMBASE (via OVID 1946 - July 2019), Cochrane, Database of Abstracts of Reviews of Effects databases and the grey literature were searched for studies reporting on older adults who were evaluated after a fall. We included prospective studies conducted in the ED where more than 80% of the cohort were 65 years or older and had fallen. We contacted study authors for aggregate data on intracranial bleeding in patients prescribed anticoagulant medication, antiplatelet medication and neither medication. Incidences of intracranial bleeding were pooled using random effect models, and I2 index was used to assess heterogeneity. Results: From 7,240 publication titles, 10 studies met inclusion criteria. The authors of 8 of these 10 studies provided data (on 9,489 patients). All studies scored low or moderate risk of bias. The pooled incidence of intracranial bleeding among patients taking an anticoagulant medication was 5.1% (n = 5,016, 95% Confidence Interval (CI): 4.1 to 6.3%) I2 = 42%, a single antiplatelet 6.4% (n = 2,148, 95% CI: 5.4 to 7.6%) I2 = 75%, both anticoagulant and antiplatelet medications 5.9% (n = 212, 95% CI: 1.3 to 13.5%) I2 = 72%, and neither of these medications 4.8% (n = 1,927, 95% CI: 3.5 to 6.2%) I2 = 50%. A sensitivity analysis restricted to patients who had a head CT in the ED reported incidences of 6.1% (n = 3,561, 95% CI: 3 to 8.3%), 8.4% (n = 1,781, 95% CI: 5.5 to 11.8%), 6.7% (n = 206, 95% CI 1.5 to 15.2%) and 6.6% (n = 1,310, 95% CI: 5.0 to 8.4%) respectively. Conclusion: The incidence of fall-related intracranial bleeding in older ED patients was similar among patients who take anticoagulant medication, antiplatelet medication, both and neither medication, although there was heterogeneity between study findings.

Introduction: We seek to characterize unhelmeted injured cyclists presenting to the emergency department (ED): demographics, cycling behaviour, and attitudes towards helmet use. Methods: This was a prospective cohort study in a downtown teaching hospital, from May 2016 - Sept 2019. Injured cyclists presenting to the ED were recruited if they were not wearing a helmet at time of injury and over age 18. Exclusion criteria included intoxication, inability to consent, or admission to hospital. A standardized survey was administered by a research coordinator. Descriptive statistics were used to summarize the data, and survey responses reported as percentages. Results: We surveyed a convenience sample of 68 unhelmeted injured cyclists (UICs) with mean age of 33.6 years (range 18 to 68, median 29.5 years). Ratio of males to females was 1:1. The majority of UICs cycled most days per week or every day in non-winter months (89.6 %, n = 60). Cycling in Toronto was perceived as somewhat dangerous (45.6%, n = 31) or very dangerous (5.9%, n = 4) by most, and very safe (2.94 %, n = 2) or somewhat safe (19.12%, n = 13) by few. Almost a third (29.4 %, n = 20) had been in a cycling accident in the prior year, some of these (15.0%, n = 3) prompting an ED visit. All cyclists were riding their personal bike (100 %, n = 68) at time of injury, and most (98.5%, n = 67) had planned to cycle when they departed home that day. Purpose of trip was primarily for commuting to work (50%, n = 34), social activities (19.1%, n = 13), school (7.4%, n = 5), and recreation (7.4%, n = 5). Bicycle helmet ownership was low (41.2 %, n = 28). UICs reported rarely (10.3%, n = 7) or never (64.7%, n = 44) wearing a helmet when cycling. Reported factors discouraging helmet use included inconvenience (33.8%, n = 23), lack of ownership (32.4%, n = 22), discomfort (29.4%, n = 20), and ‘messed hair’ (14.7%, n = 10). Few characterized helmets as unnecessary (10.3%, n = 7) or ineffective (1.5%, n = 1). The majority had a college diploma or more advanced education (77.9%, n = 53), and spoke English at home (85.3%, n = 58). Conclusion: Unhelmeted injured cyclists surveyed were frequent commuter cyclists who do not regard cycling as safe, yet choose not to wear helmets for reasons largely related to convenience rather than perceptions regarding safety or necessity. Initiatives to increase helmet use in this subgroup should address the reasons given for not wearing a helmet, potentially using principles of adult education and behavioral economics.

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

Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.

Introduction: Clinical assessment of patients with mTBI is challenging and overuse of head CT in the emergency department (ED) is a major problem. During the last decades, studies have attempted to reduce unnecessary head CTs following a mTBI by identifying new tools aiming to predict intracranial bleeding. S100B serum protein level might be helpful reducing those imaging since a higher level of S-100B protein has been associated with intracranial hemorrhage following a mTBI in previous literature. The main objective of this study was to assess whether the S100B serum protein level is associated with clinically important brain injury and could be used to reduce the number of head CT following a mTBI. Methods: This prospective multicenter cohort study was conducted in five Canadian ED. MTBI patients with a Glasgow Coma Scale (GCS) score of 13-15 in the ED and a blood sample drawn within 24-hours after the injury were included. S-100B protein was analyzed using enzyme-linked immunosorbent assay (ELISA). All types of intracranial bleedings were reviewed by a radiologist who was blinded to the biomarker results. The main outcome was the presence of clinically important brain injury. Results: A total of 476 patients were included. Mean age was 41 ± 18 years old and 150 (31.5%) were female. Twenty-four (5.0%) patients had a clinically significant intracranial hemorrhage while 37 (7.8%) had any type of intracranial bleeding. S100B median value (Q1-Q3) of was: 0.043 ug/L (0.008-0.080) for patients with clinically important brain injury versus 0.039 μg/L (0.023-0.059) for patients without clinically important brain injury. Sensitivity and specificity of the S100B protein level, if used alone to detect clinically important brain injury, were 16.7% (95% CI 4.7-37.4) and 88.5% (95% CI 85.2-91.3), respectively. Conclusion: S100B serum protein level was not associated with clinically significant intracranial hemorrhage in mTBI patients. This protein did not appear to be useful to reduce the number of CT prescribed in the ED and would have missed many clinically important brain injuries. Future research should focus on different ways to assess mTBI patient and ultimately reduce unnecessary head CT.

Introduction: Mild traumatic brain injury (mTBI) is a serious public health issue and as much as one third of mTBI patients could be affected by persistent post-concussion symptoms (PPCS) three months after their injury. Even though a significant proportion of all mTBIs are sports-related (SR), little is known on the recovery process of SR mTBI patients and the potential differences between SR mTBI and patients who suffered non-sports-related mTBI. The objective of this study was to describe the evolution of PPCS among patients who sustained a SR mTBI compared to those who sustained non sport-related mTBI. Methods: This Canadian multicenter prospective cohort study included patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of Emergency Department (ED) visit, with a Glasgow Coma Scale score of 13-15. Patients who were hospitalized following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. Three follow-up phone interviews were conducted by a research nurse at 7, 30 and 90 days post-injury to assess symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to demonstrate the impact of the mechanism of injury (sports vs non-sports) on the presence and severity of PPCS. Results: A total of 1676 mTBI patients were included, 358 (21.4%) of which sustained a SR mTBI. At 90 days post-injury, patients who suffered a SR mTBI seemed to be significantly less affected by fatigue (RR: 0.70 (95% CI: 0.50-0.97)) and irritability (RR: 0.60 (95% CI: 0.38-0.94)). However, no difference was observed between the two groups regarding each other symptom evaluated in the RPQ. Moreover, the proportion of patients with three symptoms or more, a score ≥21 on the RPQ and those who did return to their normal activities were also comparable. Conclusion: Although persistent post-concussion symptoms are slightly different depending on the mechanism of trauma, our results show that patients who sustained SR-mTBI could be at lower risk of experiencing some types of symptoms 90 days post-injury, in particular, fatigue and irritability.

Introduction: The emergency department (ED) is the first point of health care contact for most head injured patients. Although early and spontaneous resolution occurs in most patients with mild traumatic brain injury (MTBI), between 15-30% develop post-concussion syndrome (PCS). To date, clinical prediction tools do not yet exist to accurately identify adult MTBI patients at risk of PCS. The objective of this study was to identify predictors of PCS within 30 days in adults with acute MTBI presenting to the ED. Methods: This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs evaluating prescribed light exercise compared to standard care. Adult (18-64 years) patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. Participants completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the presence of PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Backward, stepwise, multivariable logistic regression with a removal criterion probability of 0.05 was conducted to determine predictor variables independently associated with PCS at 30 days. Likelihood ratio tests were used to determine appropriate inclusion of variables in the multivariable model. Results are reported as odds ratios (OR) with 95% confidence intervals (CIs). Results: A total of 367 patients were enrolled, 18 (4.9%) withdrew, and 108 (29.4%) were lost to follow-up. Median (IQR) age was 32 (25 to 48) years, and 201 (57.6%) were female. Of the 241 patients who completed follow-up, 49 (20.3%) had PCS at 30 days. Headache at ED presentation (OR = 6.59; 95% CI: 1.31 to 33.11), being under the influence of drugs or alcohol at the time of injury (OR = 4.42; 95% CI: 1.31 to 14.88), the injury occurring via bike or motor vehicle collision (OR = 2.98; 95% CI: 1.39 to 6.40), history of anxiety or depression (OR = 2.49; 95% CI: 1.23 to 5.03), and the sensation of numbness or tingling at ED presentation (OR = 2.25; 95% CI: 1.04 to 4.88), were independently associated with PCS at 30 days. Conclusion: Five variables were found to be significant predictors of PCS. Although MTBI is a self-limited condition in the majority of patients, patients with these risk factors should be considered high risk and flagged for early follow-up. There continues to be an urgent need for a clinical prognostic tool that accurately identifies adult patients at risk for PCS early in their injury.

Introduction: Patients hospitalized following a trauma will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase (< 3 months) opioid use after discharge and the risk of opioid poisoning (OP) or opioid use disorder (OUD) in older trauma patients Methods: In a retrospective multicenter cohort study conducted on registry data, we included all patients aged 65 years and older admitted (hospital stay >2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for OP and OUD from ICD-9 and ICD-10 code diagnosis that resulted in a hospitalization or a medical consultation after their initial injury. Patients that filled an opioid prescription within a 3-month period after sustaining the trauma were compared to those who did not fill an opioid prescription during that period using Cox proportional hazards regressions. Results: A total of 70,314 participants were retained for analysis; median age was 82 years (IQR: 75-87), 68% were women, and 34% of the patients filled an opioid prescription within 3-months of the initial trauma. During a median follow-up of 2.6 years (IQR: 1-5), 192 participants (0.30%; 95%CI: 0.25%-0.35%) were hospitalized for OP and 73 (0.10%; 95%CI: 0.07%-0.13%) were diagnosed with OUD. Having filled an opioid prescription within 3-months of injury was associated with an increased hazard ratio of OP (2.6; 95%CI: 1.9-3.5) and OUD (4.0; 95%CI: 2.3-7.0). However, history of OP (2.7; 95%CI: 1.2-6.1), of substance use disorder (4.3; 95%CI: 2.4-7.9), or of opioid prescription filled (2.7; 95%CI: 2.1-3.5) before trauma were also related to OP or OUD. Conclusion: Opioid poisoning and opioid use disorder are rare events after hospitalization for trauma in older patients. However, opioids should be used cautiously in patients with history of substance use disorder, opioid poisoning or opioid use during the past year.

Introduction: Hemorrhage is the primary cause of death in 39% of trauma patients. In prehospital trauma management, there is debate over pursuing a ‘scoop-and-run’ approach versus early intravenous (IV) fluid therapy. We evaluated the literature regarding the effect of prehospital IV fluid therapy on mortality in adult trauma patients. Methods: A librarian-assisted search was conducted in PubMed, Medline and Embase. The population was adults with blunt and/or penetrating trauma. The intervention was total prehospital IV fluid volume 0-500 mL, and the control was prehospital fluid volume >500 mL. The outcome of interest was in-hospital mortality. Randomized controlled trials (RCTs), cohort and case-matched studies were included. Two reviewers used the Cochrane Risk of Bias (RoB) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools to evaluate biases, and kappa was calculated for inter-rater agreement. A summary relative risk (RR) of in-hospital mortality was calculated and heterogeneity (I2) analysis performed using RevMan 5 software. Results: Four RCT's and eleven observational studies were identified, with n = 15,448 patients. Two RCTs and four observational studies were excluded due to non-English language, and the location or volume of IV fluid administered, leaving eight studies with n = 4,568 patients. Inter-rater agreement was high with the ROBINS-I (unweighted κ=0.8841) and RoB tool (unweighted κ=0.8276). Two studies found decreased mortality, one found increased mortality, and five found no significant relationship to mortality with 0-500 mL prehospital IV fluid. The summary relative risk of mortality with 0-500 mL IV fluid compared to >500 mL IV fluid was not significant (RR = 0.98 [0.87, 1.11]). The heterogeneity for all studies was high (I2 = 84%), but was low (I2 = 0%) with removal of two studies. Conclusion: The majority of studies did not find a relationship between the volume of prehospital IV fluids and in-hospital mortality. Study heterogeneity was low except for two studies: this may be explained by mortality only being recorded at emergency department discharge in one study, and the high rate of penetrating gunshot and stabbing wounds in the other. There is a paucity of high-quality RCTs on the topic, and many studies are at significant risk of bias. Further research is needed to delineate the best approach to IV fluid therapy in adult trauma patients.

Introduction: Traumatic rib fractures (RF) are a common occurrence with 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and reducing morbidity and mortality. There is evidence of intravenous (IV) lidocaine's effectiveness and safety in the post-operative thoracic and abdominal surgical patient and we hypothesize that it may be ideal in trauma patients with RF. We evaluated IV lidocaine's analgesic efficacy in this population. Methods: A single-centre, double-blind, randomized control trial comparing a 72-96 hour IV lidocaine infusion plus standard analgesics to placebo infusion plus standard analgesics. Participants were adult trauma patients diagnosed with two or more RFs requiring hospital admission. A total of 36 patients were enrolled over 5 months in 2019. The study was powered to detect a 20% reduction in pain scores, which is determined to be clinically significant. Results: The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). There were consistent trends toward reduced VAS pain scores at rest and with movement in the lidocaine group as compared to placebo group with mean scores of 3.49 [SD 2.02 95% CI] and 7.08 [SD 1.71 95% CI] in the lidocaine group and 3.83 [SD 1.93 95% CI] and 8.03 [SD 1.44 95% CI] in the placebo group, at rest (p value 0.624) and with movement (p value 0.110), respectively . Secondary outcomes were patient satisfaction as measured on the VAS which demonstrated a score of 7.79 [SD 1.82 95% CI] in the lidocaine group and 6.63 [SD 1.77 95% CI] (p = 112) in the placebo group, and total morphine equivalents (ME) used (including breakthrough doses) that demonstrated a trend towards a reduction in the lidocaine group with 210.9 mg [SD 180.0 95% CI] compared to the placebo with total ME used of 309.9 mg [SD 221.8 95% CI]. Other secondary outcomes were protocol adherence, incidence of respiratory failure, hospital and ICU length of stay, mortality, incidence of lidocaine toxicity, and treatment regimens (non-opioid analgesics). Conclusion: These results demonstrate a trend towards lidocaine's analgesic benefit during rest and the critical times of patient movement and mobility, which has been demonstrated to be paramount in the reduction of respiratory complications from rib fractures. The results also tend towards a reduction in morphine equivalents, although the trial was not powered to demonstrate this

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

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

Introduction: Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED). Methods: We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison. Results: All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99). Conclusion: Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.