Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rapidly evolving technology for clinical use in patients with refractory cardiogenic arrest. Out-of-hospital cardiac arrest (OHCA) is a common cause of unexpected death and has a low survival rate. There is increasing evidence that suggests better outcomes for (OHCA) patients, including improved neurological outcomes and survival rates, who are started on extracorporeal corporeal membrane oxygenation (ECMO) versus traditional resuscitation methods. Methods: We conducted a retrospective chart review of 200 out-of-hospital cardiac arrest patients presenting to Regina emergency departments from January 1, 2017 to March 31, 2019. Eligibility for ECPR was assessed using different clinical criteria from different ECPR programs (University of British Columbia, University of Michigan, and a hypothetical “Regina” criteria created for this study). Outcomes of the eligible patients were compared using descriptive statistics with SPSS version 22. Results: Between four different criteria, 15%, 9.5%, 7.5%, and 3.5% of patients were respectively eligible to receive ECPR. Of patients who met eligibility for all four criteria, 80% were male, the average age was 61 years old, the average Cerebral Performance score was 4.46, and 83% died in hospital. There was a low survival rate of eligible patients, with rates of 16%, 17%, 20%, and 28% in each group. The survival rate for all patients was 21% and the average CPC score was 4.35. Conclusion: The significant percentage of patients were eligible for ECPR upon presentation to Regina Emergency Departments. Patients who were eligible had low survival rates and poor neurological outcomes, suggesting that ECPR could prove to be a valuable clinical tool that could improve patient outcomes in Saskatchewan. There were considerable differences in patient eligibility percentages based on different criterion. Differences in inclusion/exclusion criteria, modifying the expected annual number of ECPR eligible OHCA patients, could provide valuable information on required resources and planning for implementation of an ECPR program in a smaller centre, such as Regina.

Background: Over 35,000 Canadians lose their lives to cardiac arrest each year. CPR and automated external defibrillator (AED) use are modifiable factors. Survival rates drop by 7-10% each minute that defibrillation is delayed, and survival rates are less than 5% after 12 minutes of ventricular fibrillation which stresses the need for bystander AED use in out-of-hospital arrests. Niagara Region lacks a publicly accessible registry of AEDs. AED access is a major focus in King County, Washington which has higher survival rates and has all AEDs registered with Emergency Medical Services. Aim Statement: This project aims to log 100 or more AEDs within a year into a publicly accessible registry and to connect the registry information to medical trainees in the Niagara region and all employees of the Niagara Health System involved in patient care. Measures & Design: PulsePoint is an application used to register AEDs within the Niagara region. PulsePoint allows users to geotag AEDs while tracking data entries. Over 16 weeks, 4 PDSA cycles tested the effectiveness of logging methods for AEDs including opportunistic logging, daily emailed reminders, and contacting organizations with high likelihood of having an AED. Information about the project and registry was shared with residents and medical students in Niagara. A second phase of cycles involves relaying information to Niagara Health system employees and the medical community. A final cycle will target a broader group of local organizations with intermediate probability of having AEDs. Primary outcome measures include the numbers of regional AEDs logged and members reached by knowledge sharing cycles. Evaluation/Results: PulsePoint was found to be an effective, free, publicly accessible resource to log AEDs within the Niagara region. The initial round of 4 PDSA cycles added a total of 56 new AEDs within the region, which were logged into PulsePoint app and the Excel spreadsheet. Through the fourth PDSA cycle, 136 businesses were contacted and made aware of the project and the AED application. In addition,138 health-related colleagues and medical students were contacted to raise awareness. PDSA cycles five through eight are currently ongoing or in the planning stages. Discussion/Impact: Raising awareness among emergency services and sharing information about the registry to local CPR training providers will be paramount. Creating awareness of PulsePoint and installing AEDs in locations that currently lack such devices could ultimately improve cardiac arrest survival rates within Niagara Region.

Introduction: Gastroenteritis (GE) is one of the most common causes of emergency room visits, especially in pediatrics. The Canadian Paediatric Society and Choosing Wisely have issued high-grade recommendations to physicians working in the Emergency Department. It suggests, trying oral ondansetron followed by oral rehydration before installing venous rehydration in children with GE with adequate hydration or mild to moderate dehydration. This quality of medical care evaluation aims to determine if these recommendations were being applied for children aged 6 months to 12 years, with adequate hydration status or mild to moderate dehydration, who presented to the Chicoutimi emergency room between November 2016 and November 2018. Methods: Practice conformity was assessed according to two explicit criteria: prescription of oral ondansetron and appropriate mean of rehydration. A data collection tool was created and files were reviewed by investigators after standardization. Several secondary outcomes were assessed, including, among others, duration of symptoms, the number of vomiting and diarrhea. The hydration status was measured according to the capillary refill, feeling of skin to the touch, condition of buccal mucosa, tears, heart rate and mental status. These variables were analyzed to understand their impact on practice conformity. We excluded cases in which there was infections needing antibiotics, hypoglycemia, hemodynamic instability, no vomiting in the last 24 hours, convulsions and history of diabetes. Results: A total of 270 patient files were analyzed, 181 of which were included. Oral ondansetron was tried in 49 % of children. Rehydration was adequate in 55% of cases. The hydration level was written in 18% of files and the hydration status noted by the emergency room physician overestimated the dehydration score in 16% of cases. When hydration status was well assessed, adequate rehydration was observed in 63% of cases, while ondansetron was attempted in only 44% of cases. Conclusion: Use of oral ondansetron and adequate mean of rehydration to treat children aged 6 months to 12 years with GE in Chicoutimi emergency department is suboptimal. The difficulty of adequate dehydration assessment may be one of the causes. Concerted dehydration assessment grid and a group prescription for the administration of ondansetron during the nurse triage may constitute potential solutions.

Introduction: Spatial ability has been defined as a skill in representing, transforming, generating and recalling symbolic, non-linguistic information. Two distinct human spatial abilities have been identified: visualization and orientation. A sex difference in spatial abilities favouring male has been documented. A pattern of negative effects with increasing age on spatial abilities has also been demonstrated. Spatial abilities have been correlated to anatomy knowledge assessment using practical examination, three-dimensional synthesis from two-dimensional views, drawing of views, and cross-sections in a systematic review. Spatial abilities have also been correlated to technical skills performance in beginners and intermediate learners in a systematic review. The objective of this study was to conduct a systematic review of the interrelationship between spatial abilities, anatomy knowledge and technical skills. Methods: Search criteria included ‘spatial abilities’, ‘anatomy knowledge’ and ‘technical skills’. Keywords related to these criteria were identified. A literature search was done up to November 9, 2018 in Scopus and in several medical and educational databases on Ovid and EBSCOhost platforms. A bank of citations was obtained and was reviewed independently by two investigators. Citations related to abstracts, literature reviews, theses and books were excluded. Articles related to retained citations were obtained and a final list of articles was established. Methods relating spatial abilities testing, anatomy knowledge assessment and technical skills performance were identified. Results: A series of 385 titles and abstracts was obtained. After duplicates were removed and selection criteria applied, 11 articles were retained, fully reviewed, and subsequently excluded with reasons. Conclusion: No eligible articles were found in a systematic review of the interrelationship between spatial abilities, anatomy knowledge and technical skills. The outcome of future studies could help to further understand the cognitive process involved in learning a technical skill in Emergency Medicine.

Background: Unintentional opioid overdoses in and around acute care hospitals, including in the ED, are of increasing concern. In April 2018, the Addiction Recovery and Community Health (ARCH) Team at the Royal Alexandra Hospital opened the first acute care Supervised Consumption Service (SCS) in North America available to inpatients. In the SCS, patients can consume substances by injection, oral or intranasal routes under nursing supervision; immediate assistance is provided if an overdose occurs. After a quality assurance review, work began to expand SCS access to ED patients as well. Aim Statement: By expanding SCS access to ED patients, we aim to reduce unintentional and unwitnessed opioid overdoses in registered ED patients to 0 per month by the end of 2020. Measures & Design: Between June 13-July 15, 2019, ARCH ED Registered Nurses were asked to identify ED patients with a history of active substance use who may potentially require SCS access. Nurses identified 69 patients over 43 8-hour shifts (range 0-4 patients per shift); thus, we anticipated an average of 5 ED patients per 24-hour period to potentially require SCS access. Based on this evidence of need, ARCH leadership worked with a) hospital legal team and Health Canada to expand SCS access to ED patients; b) ED leadership to develop a procedure and flowchart for ED SCS access. ED patients were able to access the SCS effective October 1, 2019. Evaluation/Results: From October 1 to December 1, 2019, the SCS had 35 visits by 23 unique ED patients. The median time spent in the SCS was 42.5 minutes (range 14.0-140.0 minutes). Methamphetamine was the most commonly used substance (19, 45.2%), followed by fentanyl (10, 23.8%); substances were all injected (91.4% into a vein and 8.6% into an existing IV). In this time period, there were zero unintentional, unwitnessed opioid poisonings in registered ED patients. Data collection is ongoing and will expand to include chief complaint, ED length of stay and discharge status. Discussion/Impact: Being able to reduce unintentional overdoses and unwitnessed injection drug use in the ED has the potential to improve both patient and staff safety. Next steps include a case series designed to examine the impact of SCS access on emergency care, retention in treatment and uptake into addiction treatment.

Introduction: The opioid epidemic has been influenced by immense marketing campaigns produced by pharmaceutical companies. These campaigns include advertisements aimed at emergency medicine (EM) physicians, which may have influenced overprescription. This study is a part of a larger effort to systematically assess opioid ads published in major medical journals in North America. To our knowledge, this is the first study to systematically assess the volume, claims, and levels of evidence for opioid ads aimed at EM physicians. Methods: Up to two issues per year from 1996 to 2016 of ten major North American medical journals were hand-searched for opioid advertisements. Specifically, we assessed random samples of issues from five major North American emergency medicine journals, including Annals of Emergency Medicine, Emergency Medicine, Canadian Journal of Emergency Medicine, Emergency Medicine Journal, and American Journal of Emergency Medicine. Five generalist medical journals were assessed including Journal of the American Medical Association, New England Journal of Medicine, Canadian Medical Association Journal, American Family Physician, and Canadian Family Physician. The volume of advertisements, nature of the claims, and cited evidence were collected by independent reviewers. The referenced evidence was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence rubric. Results: Of the 269 issues across the ten journals, opioid ads compromised 95 of the 3392 pharmaceutical advertisements with 79 opioid ads available for analysis. When analysis was completed with two reviewers, inter-rater agreement was rated as 99.87 (Cohen's kappa of 0.976). 37/79 ads did not mention the addictive potential of opioids, with 60/79 not mentioning the possibility of death. The tamper potential of medications was mentioned in 27/79 ads. Positive claims included efficacy (47/79), fast-acting ability (16/79), patient preference (5/79), convenience (26/79) and reduced side effects (22/79). 26/79 cited references directly in their text. Citations were provided for a total of 19 available original studies, of which a majority (16/19) were Level 2 evidence. Upon examination of conflicts of interest, 100% (19/19) of the referenced studies were funded by a pharmaceutical company. Conclusion: A variety of claims were published in medical journals through opioid advertisements, which cite industry studies. Many ads did not mention key negative information, which may have influenced EM physician prescribing.

Introduction: The study of artificial intelligence (AI) in medicine has become increasingly popular over the last decade. The emergency department (ED) is uniquely situated to benefit from AI due to its power of diagnostic prediction, and its ability to continuously improve with time. However, there is a lack of understanding of the breadth and scope of AI applications in emergency medicine, and evidence supporting its use. Methods: Our scoping review was completed according to PRISMA-ScR guidelines and was published a priori on Open Science Forum. We systematically searched databases (Medline-OVID, EMBASE, CINAHL, and IEEE) for AI interventions relevant to the ED. Study selection and data extraction was performed independently by two investigators. We categorized studies based on type of AI model used, location of intervention, clinical focus, intervention sub-type, and type of comparator. Results: Of the 1483 original database citations, a total of 181 studies were included in the scoping review. Inter-rater reliability for study screening for titles and abstracts was 89.1%, and for full-text review was 77.8%. Overall, we found that 44 (24.3%) studies utilized supervised learning, 63 (34.8%) studies evaluated unsupervised learning, and 13 (7.2%) studies utilized natural language processing. 17 (9.4%) studies were conducted in the pre-hospital environment, with the remainder occurring either in the ED or the trauma bay. The majority of interventions centered around prediction (n = 73, 40.3%). 48 studies (25.5%) analyzed AI interventions for diagnosis. 23 (12.7%) interventions focused on diagnostic imaging. 89 (49.2%) studies did not have a comparator to their AI intervention. 63 (34.8%) studies used statistical models as a comparator, 19 (10.5%) of which were clinical decision making tools. 15 (8.3%) studies used humans as comparators, with 12 of the 15 (80%) studies showing superiority in favour of the AI intervention when compared to a human. Conclusion: AI-related research is rapidly increasing in emergency medicine. AI interventions are heterogeneous in both purpose and design, but primarily focus on predictive modeling. Most studies do not involve a human comparator and lack information on patient-oriented outcomes. While some studies show promising results for AI-based interventions, there remains uncertainty regarding their superiority over standard practice, and further research is needed prior to clinical implementation.

Introduction: Patients frequently present to the Emergency Department (ED) with predictable complications associated with radiation and chemotherapy for active cancer. Care alternatives have been proposed to reduce ED visits; however, no systematic review related to ED presentations has been completed. The objective of this scoping review was to examine the effectiveness of interventions designed to reduce ED visits among patients receiving active cancer treatment. Methods: A comprehensive literature search involving nine electronic databases and the grey literature was completed. Inclusion criteria considered studies assessing the impact of any intervention to reduce ED utilization among patients with active cancer. Two reviewers independently assessed relevance and inclusion; disagreements were resolved through third party adjudication. Dichotomous and continuous outcomes were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs) using a random-effects model, wherever appropriate. Results: From 3303 citations, a total of 25 studies were included. Interventions identified in these studies comprised: routine and symptom-based patient follow-up, oncology outpatient clinics, early symptom detection, comprehensive inpatient management, hospital at home, and patient navigators. Six out of eight studies assessing oncology outpatient clinics reported a decrease in the proportion of patients presenting to the ED. A meta-analysis of three of these studies did not demonstrate reduction in ED utilization (RR 0.78; 95% CI: 0.56 to 1.08; I2 = 77%) when comparing oncology outpatient clinics to standard care; however, sensitivity analysis removing one study reporting rare events supported a decrease in ED visits (RR 0.86; 95% CI: 0.74 to 0.99; I2 = 47%). Three studies assessing patient follow-up interventions showed no difference in ED utilization (RR 0.69; 95% CI: 0.38 to 1.25; I2 = 86%). Conclusion: A variety of interventions designed to mitigate ED presentations by patients receiving active cancer treatment have been developed and evaluated. Limited evidence suggests that an oncology outpatient clinic may be an effective strategy to reduce ED utilization; however, additional high-quality studies are needed.

Innovation Concept: Effective communication for ad hoc teams is critical to successful management of multisystem trauma patients, to improve situational awareness and to mitigate risk of error. OBJECTIVES 1. Improve communication of ad hoc teams. 2. Identify system gaps. INNOVATION Team in situ simulations provide a unique opportunity to practice communication and assess systems in the real environment. Our trauma team consists of residents and staff from emergency services, general surgery, orthopedics, anaesthesia, nursing and respiratory therapy. Methods: A team of subject matter experts (SME's) from trauma, nursing, emergency medicine and simulation co-developed curriculum in response to a needs assessment that identified gaps in systems and team communication. The simulation occurred in the actual trauma bay. The on-call trauma team was paged and expected to manage a simulated multisystem trauma patient. Once the team arrived, they participated in a briefing, manikin-based simulation and a communication and system focused debriefing. Curriculum, Tool, or Material: Monthly scenarios consisted of management of a blunt trauma patient, emergency airway and massive hemorrhage protocol. Teams were assessed on communication skills and timeliness of interventions. Debriefing consisted of identification of system gaps and latent safety threats. Feedback was given by each discipline followed by SME's. Information was gathered from participant evaluations (5-point Likert scale and open ended questions) and group debrief. Feedback was themed and actions taken to co-create interventions to communication gaps and latent safety threats. As a result, cricothyroidotomy trays were standardized throughout the hospital to mitigate confusion, time delay and unfamiliarity during difficult airway interventions. Participants felt the exercise was an effective means of practicing interprofessional communication and role clarity, and improved their attitude towards the same. Conclusion: In situ simulation-based education with ad hoc trauma teams can improve interprofessional communication and identify latent safety threats for the management of multisystem trauma patients.

Introduction: Affecting roughly 1 in 5 pregnancies, early pregnancy loss is a common experience for reproductive-aged women. In Canada, most women do not establish care with an obstetrical provider until the second trimester of pregnancy. Consequently, pregnant patients experiencing symptoms of early pregnancy loss frequently access care in the emergency department (ED). The objective of this study was to describe the resource utilization and outcomes of women presenting to two Ontario EDs for early pregnancy loss or threatened early pregnancy loss. Methods: This was a retrospective cohort study of pregnant (≤20 weeks), adult (≥18 years) women in two EDs (one community hospital with 110,000 annual ED visits; one academic hospital with 65,000 annual ED visits) between January 2010 and December 2017. Patients were identified by diagnostic codes indicating early pregnancy loss or threatened early pregnancy loss. Results: A total of 16,091 patients were included, with a mean (SD) age of 32.8 (5.6) years. Patients had a total of 22,410 ED visits for early pregnancy complications, accounting for 1.6% of the EDs’ combined visits during the study period. Threatened abortion (n = 11,265, 50.3%) was the most common ED diagnosis, followed by spontaneous abortion (n = 5,652, 25.2%), ectopic pregnancy (n = 3,242, 14.5%), missed abortion (n = 1,541, 6.9%), and other diagnoses (n = 710, 3.2%). 8,000 (44.8%) patients had a radiologist-interpreted ultrasound performed during the initial ED visit. Median (IQR) ED length of stay was 3.4 (2.3 to 5.1) hours. There were 4,561 (25.6%) return ED visits within 30 days, of which 2,317 (50.8%) occurred less than 24 hours of index visit, and 481 (10.6%) were for scheduled, next day ultrasound. The total number of hospital admissions was 1,793 (8.0%), and the majority were for ectopic pregnancy (n = 1,052, 58.7%). Of admitted patients, 1,320 (73.6%) underwent surgical interventions related to early pregnancy. There were 474 (10.4%) patients admitted to hospital during return ED visits. Conclusion: Pregnant patients experiencing symptoms of early pregnancy loss in the ED frequently had radiologist-interpreted US and low rates of hospital admission, yet had high rates of return ED visits. This study highlights the heavy reliance on Ontario EDs to care for patients experiencing complications of early pregnancy.

Introduction: We sought to assess the effect of in-hospital targeted temperature management (TTM) on outcomes of non-shockable out-of-hospital cardiac arrest (OHCA). Methods: This is a secondary analysis of a randomized controlled trial “A Randomized Trial of Continuous Versus Interrupted Chest Compressions in Out-of-Hospital Cardiac Arrest” (NCT01372748). We included non-traumatic comatose OHCAs with non-shockable rhythm who survived to hospital admission. Outcomes of interest were survival at hospital discharge and favorable neurological outcome (modified Rankin scale 0-3). We performed multivariable logistic regression, adjusting for baseline characteristics to determine the association between TTM and outcomes, compared to no TTM, for the entire cohort as well as for the propensity matched cohort. Results: Of 1,985 OHCAs who survived to hospital admission, 780 (39.3%) were managed with TTM. In TTM patients, 7.3 % patients survived to hospital discharge and 3.9 % had a favorable neurological outcome in contrast to 10.2 % and 6.1 %, respectively, in no TTM patients. Multivariable analyses demonstrated an association between TTM and decreased probability of both outcomes, compared to no TTM (adjusted ORs for survival: 0.67 95% CI 0.48–0.93, and for favorable neurological outcome: 0.57 95% CI 0.37–0.90). Propensity score matched analyses demonstrate the similar results. Conclusion: TTM might decrease the probability of neurologically intact survival for non-shockable OHCAs.

Introduction: Children with concussions presenting to emergency departments often receive very different recommendations for how to recover. In addition, there are no instructions for teachers to how children should return to learn and play after a concussion. Therefore, some children take too long to return to learn and play at school while others return too soon, thereby risking long-term problems because their brain injury is not fully healed. The purpose of this project is to determine the impact of a new integrated, standardized approach aimed to help a concussed child recover faster and whether the recovery experience for all involved has improved. Methods: Structured interviews were conducted with 11 parents of children treated for concussion at the Emergency Department of Pasqua Hospital in Regina, SK, four of whom received care after a change in practice whereby parents were provided with a return-to-school protocol form prior to discharge. Data were analyzed using an inductive qualitative content analysis approach using NVivo 12 software. Results: Three main categories were noted in the data: Parental response to the child's concussion, satisfaction with health services, and the communication amongst parents, physicians, and teachers. It was with regard to the last theme in particular that the impact of the return to school protocol was noted, helping to at least indirectly address the issue of the parent as the “middleman” in the communication triad. Most parents whose children received care prior to the introduction of the protocol suggested that providing written information at discharge to guide parents through the concussion recovery process would be helpful. Conclusion: Our initial results show a positive impact in regards to the process of children returning to learn and play after a concussion. Specifically, the increased communication between physician, teacher, and parent seems to benefit and improve the child's recovery process.

Introduction: Despite studies highlighting the inaccuracies of self-assessment, practicing physicians continue to rely on self-perception to maintain clinical competence. Many approaches have been proposed to augment physician performance. In the realm of Quality Improvement (QI), Audit and Feedback (A&F) has a modest effect. Educators have proposed coaching interventions and academic constructs have invoked training for early-career clinicians. Very few of these are driven by the perceptions and the needs of the end-user - the physicians. We currently lack a model to understand physicians’ perceptions of their own practice data and an understanding of the factors which would enable practice change. In this study, we sought to develop a model for data feedback which may best help physicians change practice. Methods: In a previous study, we conducted a needs analysis of 105 physicians in the Hamilton-Niagara area in order to understand which data metrics were most valuable to physicians. Using the survey results, we designed an interview guide that was used as a qualitative study of physicians’ perspectives on A&F. By intentional sampling, we recruited 15 physicians amongst gender groups, types of practice (academic vs community) and durations of practice. We conducted this interview with all 15 participants which were then transcribed. We then performed thematic analysis and extraction of all interviews using a realist framework. These were then translated into broader themes and, by using a grounded theory framework, created a model to understand how physicians relate practice data to their own sense of self. Interviews were anonymized and no identifying data was shared as part of the interview. All interviewees consented to participation at the outset and could withdraw at any time. Results: Via stakeholder interviews from 15 key informants, we developed a model for the understanding of how a physician's sense of self and the nature of the data (quantity and quality) may be combined to understand the likelihood of practice change and the adoption of the change strategy. Using this model, it is possible to understand the conditions under which A&F would provide the greatest opportunity for practice change. Conclusion: Physician identity intersects with A&F data to shed insights on practice improvement. Understanding the core identity constructs of different physician groups may allow for increased uptake in A&F processes.

Introduction: Despite being legal in Canada, the vaporized liquid of vaping systems contains several chemicals presenting unknown risks to lung health and little is known about their use in patients visiting the emergency department (ED). This study explores associations between exposure to inhaled products and respiratory presentations in the ED. Methods: A cross-sectional lung health survey among patients presenting to a Canadian ED was conducted, exploring the association between inhaled toxic exposures (e.g., vaping, cannabis and cigarette smoking) and visits related to respiratory symptoms. Eligible participants were ambulatory (CTAS 2 to 5), stable, adults (≥ 17 years) visiting the ED from July to November, 2019. Results are described as frequencies and percentages (categorical variables) and medians with interquartile range (IQR, continuous variables). Univariate and multivariate logistic regression models report associations as odds ratios (OR) with 95% confidence intervals (CIs). The Health Research Ethics Board approved the study. Results: From 1433 eligible patients, 1024 (71%) completed the survey. The median age was 43.5 (IQR: 29, 60), and 51% were female. Overall, 177 (17%) reported ≥1 respiratory symptoms and 83 (8%) reported using any vaping products. In a univariate regression analysis, exposure to vaping was positively associated with ED visits related to respiratory symptoms (OR 2.11, 95% CI: 1.26 to 3.54). In the multivariate model, vaping and a previous diagnosis of ≥1 respiratory conditions showed positive association with respiratory-related ED visits (OR 1.86, 95% CI: 1.03 to 3.33; and OR 2.13, 95% CI: 1.50 to 3.02, respectively). There was evidence of an additive effect of the combined exposure to cigarettes and vaping and respiratory-related ED visits (OR 3.22, 95% CI: 1.61 to 6.43). Smoking cannabis and cigarettes alone were not associated with increased risk of respiratory-related visits. Conclusion: Using vaping products increased the occurrence of respiratory-related ED visits, particularly in people with pre-existing lung conditions. A dose-response relationship exists where the risk is highest in patients inhaling a combination of toxins. Contrary to previous assumptions, the use of vaping products has a negative impact on lung health.

Background: Clinical handover between emergency medical services (EMS) and the hospital trauma team can be subject to errors that may negatively affect patient care. Thus far, there has been limited evaluation of the quality of EMS handover. As such, we sought to characterize handover practices from EMS to the trauma team, identify areas for improvement, and determine if there is a need for standardization of current handover practices. Aim Statement: Identify areas for improvement in handover from EMS to the trauma team, specifically examining handover content, structure, and discordances between different team members regarding handover expectations. Measures & Design: Data were prospectively collected over a nine week period by a trained observer at Canada's largest level one trauma centre. A randomized scheduled was used to capture a representative breadth of handovers. Data collected included outcome measures such as duration of handover, structure of the handover, and information shared, process measures such as questions and interruptions from the trauma team, and perceptions of the handover from nurses, trauma team leaders (TTLs) and EMS according to a bidirectional Likert scale. Evaluation/Results: Of 410 trauma team activations, 79 verbal handovers were observed. Information was often missing regarding airway (present 22%), breathing (54%), medications (59%), and allergies (54%). Handover structure lacked consistency beyond the order of identification and mechanism of injury. Only 28% of handovers had a dedicated question and answer period. Of all questions asked, 35% were questioning previously given information. EMS returned to categories of information unprompted in 84% of handovers. The majority of handovers (61%) involved parallel conversations between team members while EMS was speaking, which was associated with a greater number of interrupting questions from the trauma team (3.15 vs. 1.82, p =.001). There was a statistically significant disparity between the self-evaluation of EMS handovers and the perceived quality determined by nurses and trauma team leaders. Discussion/Impact: At our trauma centre, we have identified the need for handover standardization due to poor information content, a lack of structure and active listening, significant information repetition, and discordant expectations between EMS, nurses, and TTLs. We intend to use our results to guide the development of a co-constructed framework integrating the perspectives of all team members on the trauma team.

Introduction: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) practitioners are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. Our goal is to enhance rural trauma care by identifying obstacles rural EM physicians face in Saskatchewan. Methods: This was a cross sectional survey study, emailed to family physicians practicing rural EM in Saskatchewan identified through the Saskatchewan Medical Association database. Inclusion criteria included physicians who are providing EM care currently or within the past year. Rural was assumed to be communities in Saskatchewan that were outside of Saskatoon and Regina. The survey was an anonymous self-assessment regarding demographics, training, hospital resources and comfort. Results: 113 physicians of the 479 rural physicians agreed to participate, 78 met our inclusion criteria. Most (67%) were from communities with less than 10,000 population, 70% had less than 300 ED visits per month. Most (68%) were less than 45 years of age. In terms of training, 57% had completed undergraduate training out of Canada and 63% had completed residency training in Canada. Most had been practicing for more than 2 years (76%). Most (59%) had current ATLS credentials, however only 37% had ever completed the EDE course. Regarding available resources, most centers had plain radiography (99%), POCUS (68%), PRBC (78%) and TXA (93%). However, fresh frozen plasma (41%) and platelets (26%) were not widely available. Comfort was measured on a Likert scale. The types of trauma that respondents were least comfortable with included pediatric (39%), vascular (46%), spine (56%) and genitourinary (60%). The types skills that participants were least comfortable with included pericardiocentesis (19%), and surgical airway (25%). The majority had not performed Pediatric endotracheal tube insertion (79%), surgical airways (99%), pericardiocentesis (99%), central venous line placement (80%) and needle thoracentesis (71%) within the past 12 months. Conclusion: This self-assessment helped us identify aspects of rural trauma medicine that are the most challenging for rural practitioners. Understanding the most difficult challenges in light of the critical resources available to rural trauma medicine providers will inform future professional development initiatives.

Introduction: Calgary's introduction of rentable electronic scooters (e-scooters) in July of 2019 was met with wild popularity, representing the third most popular launch after Tel-Aviv and Paris. The present study aims to characterize the injury burden seen in all Calgary Emergency Departments (EDs) and Urgent Care Centres (UCCs) attributable to e-scooters since their 2019 introduction. Methods: We retrospectively reviewed all electronic medical records of patients presenting to Calgary EDs or UCCs with the term “scooter” in the triage note, where exclusion criteria are considered for non e-scooter injuries (e.g: non-motorized scooters). Trends in scooter injuries will be compared between April - October 2018 (control arm preceding e-scooter introduction) and April - October 2019. Injury incidence, types, patient demographics, and relative risk compared to bicycle-related injuries will be determined. Descriptive statistics will be calculated. Moreover, 33 ED visits were brought in by EMS and provide information about injury types and locations of injuries involving EMS transport. Results: Preliminary data reveals 540 scooter-related visits (3.10% admitted/transferred) between July 8th and September 30th 2019 (mean age of 28, 56.30% male). Conversely, the number of bicycle-related visits and motor vehicle related injuries were 1482 and 586 (9.90% and 9.70% admitted/transferred) respectively over the same time period suggesting a greater burden but likely a lower per-ride incidence of injury requiring ED or UCC care. Moreover, between July 8th to October 1st 2019, 33 e-scooter presentations involved EMS (21.21% admitted to hospital), where 12.12% involved upper extremity injury, 21.21% were lower extremity injuries, and 6.06% were head injuries (mean age of 34, 48.48% male). Conversely, estimated EMS transfers to EDs or UCCs for bicycle injuries and motor vehicle injuries were 197 and 463 respectively over the same time period. ICU admissions or fatality were not recorded. Conclusion: Representing the most comprehensive study of e-scooter injury patterns in Canada to date, we here demonstrate a significant injury burden attributable to e-scooters following their introduction in Calgary in 2019. Bicycle-related and motor vehicle injuries were both more prevalent in this time period, and required more EMS visits. Further characterization of injury types, injuries and comparison with injury patterns prior to e-scooter introduction is yet to be determined.

Introduction: Incidental findings (IFs) are findings discovered in the course of healthcare (e.g., blood tests, genetic tests, imaging) that are unrelated to the primary purpose for which a test was sought. Some IFs constitute new knowledge that have implications for patient autonomy and welfare. IFs found in emergency departments (EDs) are difficult to manage, with one study reporting that of 392 patients with IFs, 122 had no follow-up and 242 had no electronic record of the finding. Methods: A critical interpretive literature review was conducted to explore current practices regarding identification, disclosure, and management of IFs in EDs, and to identify ethical challenges that require research focus and policy reform. The search strategy included ‘incidental findings’ AND ‘emergency’ and derivatives, retrieving 12,021 studies from databases including PubMed, Scopus, and Web of Science, as well as handsearching and reference list searching. Following screening, 97 studies were included. Data was extracted, analyzed using descriptive statistics, and then critically interpreted to capture key ideas. Results: Of 97 included articles, 75 have relevant empirical data. Of the 75, most literature (89%) presented the frequency of IFs in EDs, with an average frequency of 34%. Most (84%) did not report on patient disclosure rates or follow-up rates. When reported, patient notification rates are as low as 2.6% with an average of 15% over 12 studies. Empirical studies included in the review do not address ethical principles or patient preferences on disclosure. The literature reveals suggestions to manage IFs in EDs, including implementation of automatic feedback or alert mechanisms, clarification of responsibilities within treating teams, protocols in radiology departments, and improvements to patient documentation. Test results by letter are noted as insufficient because patients are unable to ask questions. Authors suggest further research on optimal follow-up recommendations to alleviate patient and physician distress. Further results will be presented, critically interpreted, and discussed, with attention to ethical implications and challenges. Conclusion: The literature on IFs in EDs focuses too narrowly on frequency, with ad hoc suggestions for practice, research, and policy changes to improve the ethical management of IFs. Numerous factors, including crucial knowledge gaps, contribute to inadequate management of IFs arising in EDs. Research and ethics informed policy guidance is needed.

Introduction: Despite the visibility of the homeless population, there is limited data on the information of this patient population. Point-in-time counts and survey data from selected samples (such as those admitted to emergency shelter) have primarily been used. This literature suggests that this hard-to-reach population has high rates of presentation at emergency departments (EDs), and as such, EDs often become their main point of contact for health and social services. Leveraging this fact and administrative data we construct a crude census of homeless persons within Ontario. We further examine demographic characteristics of patients experiencing homelessness, and compare this data to findings from previous literature. Methods: All routinely collected administrative health data from EDs located within Ontario, Canada from 2010-2017 were analyzed to examine patient characteristics. Individuals experiencing homelessness were identified by a marker that was adopted in 2009 replacing their recorded postal code with an XX designation. s. Aggregating by LHIN, date and week of year, we examine the overall number of patients experiencing homelessness and number by LHIN location and seasonality. Demographic outcomes examined include age and sex. Results: 640,897 visits to the ED over 7 years were made by 39,525 unique individuals experiencing homelessness. Number of ED visits has steadily increased over 10 years in all of Ontario, despite decline in shelter use for individuals. Presentations were concentrated in large urban centres like Toronto, Ottawa and Hamilton. Fewer presentations occur in the spring and summer months and rise in the winter. Male patients presented older and in greater numbers than female patients. The modal female age of presentation is in the 20-24 age category. The modal male age of presentation is in the 25-29 age category. Older male patients were more likely to have multiple presentations. Conclusion: The utilization of administrative health data offers a novel, cost-effective method to measure demographic characteristics of people experiencing homelessness. Identifying characteristics of homeless patients through this method allows for a more complete understanding of the characteristics of a hard-to-reach population, which will allow policy makers to develop appropriate services for this sub-group. Furthermore, through analysis of trends of demographics over time, changes in the homeless population can be tracked in real-time to allow for coordination and implementation of services in a time-sensitive manner.

Introduction: Administrative data can aid in study and intervention design, incorporating hard-to-reach individuals who may otherwise be poorly represented. We aim to use administrative health data to examine emergency department visits by people experiencing homelessness and explore the application of this data for planning interventions. Methods: We conducted a serial cross-sectional study examining emergency department use by people experiencing homelessness and non-homeless individuals in the Niagara region of Ontario, Canada. The study period included administrative health data from April 1st, 2010 to March 31st, 2018. Outcomes included number of visits, number of unique patients; group proportions of Canadian Triage and Acuity Scale (CTAS) scores; time spent in emergency; and time to see an MD. Descriptive statistics were generated, and t-tests were performed for point estimates and a Mann-Whitney U test for distributional measures. Results: Our data included 1,486,699 emergency department visits. The number of unique people experiencing homelessness ranged from 91 in 2010 to 344 in 2017, trending higher over the study period compared to non-homeless patients. The rate of visits increased from 1.7 to 2.8 per person. People experiencing homelessness tend to present later in the day and with higher overall acuity as compared to the general population. Time in emergency department and time to see an MD were greater among people experiencing homelessness. Conclusion: Administrative health data allows researchers to enhance interventions and models of care to improve services for vulnerable populations. Given the challenging fiscal realities of research, our study provides insights to more effectively target interventions for vulnerable populations.