Introduction: About 20% of TIAs are due to large vessel disease. Carotid stenosis >50% which is causing a TIA or stroke needs to be definitely managed quickly in order to benefit. Alternatively, dual antiplatelet therapy may be considered. The objective of this study was to determine high-risk diagnostic findings associated with symptomatic carotid disease in ED patients with TIA to indicate patients requiring urgent carotid imaging. Methods: We performed a prospective Canadian multicenter cohort study, at 13 academic sites, of ED patients with TIA or non-disabling stroke from 2006-2014. Study research nurses recorded imaging findings on standardized data collection forms from the final reports of all imaging tests ordered in the ED on prospectively enrolled patients by treating emergency physicians. Symptomatic carotid disease was defined as carotid stenosis 50-99% or carotid dissection and was adjudicated by stroke neurology to be the etiology of the index event. Patients were followed by medical review and telephone up to 90 days. Univariate analysis was conducted for investigation results with our primary outcome. Results: The cohort included 305 patients with and 5,277 without symptomatic carotid disease. Positive predictors of symptomatic carotid disease included platelet count over 400 x 109/L (15.3% vs 7.6%; p=0.0095), blood glucose >15 mmol/L (11.4% vs 4.4%; p<0.0001), CT evidence of acute infarction (9.8% vs 4.1%; p<0.0001), CT evidence of old infarction (35.7% vs 24.1%; p<0.0001), and CT evidence of any infarct (43.3% vs 26.7%; p<0.0001). There were no negative predictors of symptomatic carotid disease. Conclusion: High-risk investigation findings suggestive of symptomatic carotid disease in ED TIA patients include platelet count over 400 x 109/L, blood glucose >15 mmol/L, CT evidence of any infarction. Patients with any of these findings should be considered for rapid carotid imaging.

Introduction: Administrative data is a useful tool for research and quality improvement; however, the validity of research findings based on these data depends on their reliability. Diagnoses are recorded using diagnostic codes, as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Several groups have reported coding errors associated with ICD-10 assignments to patient diagnoses; these errors have serious implications for research, quality improvement, and policymaking. As part of a quality improvement project targeting emergency department (ED) diagnostic appropriateness for pulmonary embolism (PE), we sought to validate the accuracy of ICD-10 codes for studying ED patients diagnosed with PE. Methods: Hospital administrative data for adult patients (age ≥18 years) with an ICD-10 code for PE (I26.0 and I26.9) were obtained from the records of four urban EDs between July 2013 to January 2015. A review of medical records and imaging reports was used to confirm the diagnosis of PE. In the case of discrepancy between ICD-10 coding and chart review, the diagnosis obtained from chart review was considered correct. The physicians’ discharge notes in the administrative database were also searched using ‘pulmonary embolism’ and ‘PE’, and patients who were diagnosed with PE but not coded as PE were identified. Coding discrepancies were quantified and described. Results: 1,453 ED patients had a PE ICD-10 code during our study period. 257 (17.7%) of these patients’ diagnoses were improperly coded. 211 patients assigned an ICD-10 PE code had ED discharge diagnoses of ‘rule-out PE’ or ‘query PE’. 64 other patients were miscoded as having a PE and should have been assigned an alternate code, such as chest pain, hypoxia, or dyspnea. The physician did not include a discharge diagnosis in 4 of the 64 miscoded patients; however, triage and physician assessment notes indicated no suspicion of PE. Furthermore, 117 patients who had an ED discharge diagnosis of PE were not assigned a PE code, meaning that 8.91% of true PEs were missed by using ICD-10 codes alone. Thus, 1,313 ED patients truly had a PE. Conclusion: Our work suggests the need for more accuracy in ICD-10 coding of ED diagnoses of PE. Caution should be exercised when using administrative data for studying PE, and validation of the accuracy of ICD-10 coding prior to research use is recommended.

Introduction: Testicular torsion is a time sensitive condition for which there can be significant delays to surgery or transfer to definitive care while trying to obtain an ultrasound to confirm the diagnosis. This study determines the test characteristics for each individual sonographic sign of testicular torsion associated with the patient requiring surgical intervention. Methods: A retrospective health records review of adult patients with acute, non-traumatic scrotal pain or swelling (defined as under 24 hours since onset) presenting to one of two Canadian academic tertiary care emergency departments between November 2009 and March 2013 was performed. A single data abstractor completed a case report form for each patient including demographics, individual ultrasound findings, final diagnosis, and need for surgical intervention. The sensitivity and specificity of each ultrasonographic sign (including testicular heterogeneity, decreased colour doppler, and decreased pulsed wave doppler) at predicting surgical intervention during the same hospital visit was calculated along with 95% confidence intervals. Results: During the study period there were a total of 876 emergency department visits for scrotal pain, of which 198 patients met our inclusion criteria. The included patients had a mean age of 36.2 years. Decreased blood flow to the painful testicle on colour doppler showed the best overall test characteristics with a sensitivity of 82.4% (95% CI 55.8%-95.3%) and specificity of 100% (95% CI 96.3%-100%) for predicting a need for surgical intervention for testicular torsion. Other ultrasound findings for testicular torsion included a heterogeneous appearance of the painful testicle (sensitivity 47.1% [95% CI 23.9%-71.5%], specificity 77.4% [95% CI 68.9%-84.2%]), and decreased arterial or venous flow on pulsed wave doppler (sensitivity 76.5% [95% CI 49.8%-92.1%], specificity 100% [95% CI 96.3%-100%]). Conclusion: Decreased blood flow to the painful testicle on colour doppler showed excellent specificity and can rapidly “rule-in” a need for surgical intervention for testicular torsion. Given that colour doppler is relatively easy to learn and perform, future studies should assess the use of colour doppler using point of care ultrasound to expedite surgical consultation.

Introduction: Patients with renal colic present frequently to the emergency department (ED). Existing literature suggests management with medical expulsion therapy (MET) may improve outcomes, especially for those with stones > 5 mm in size. This study evaluates the use of MET in the management of adult patients seen in regional EDs with a diagnosis of renal colic. Methods: A multi-centered medical chart review study was conducted in seven Edmonton-Zone EDs. Approximately 100 cases from each site were randomly selected from administrative data from the 2014 calendar year, no repeat cases were permitted. Using a standardized data collection process and trained research assistance, data were abstracted from medical charts. Medians and inter-quartile ranges (IQR), proportions, and odds ratios (OR) with 95% confidence intervals (CIs) are reported. Results: Overall, 656 patient charts were included in the review; median age was 46 years (IQR: 35, 46) and 249 (38%) were female. Few (10%) arrived by ambulance or were on MET therapy at presentation; however, many (51%) reported a previous episode of renal colic. Many (191 {29%}) received no initial ED imaging; CT (236 {36%}) was favoured over ultrasound (39 {6%}) for initial imaging, either alone or with plain radiographs (8%). Plain radiographs were frequently ordered (204 {31%}). Only 198 (31%) of charts contained documentation of the use of MET at discharge and the median duration of therapy was 10 days (IQR: 7, 14). Initiation of MET therapy did not vary based on older age (OR = 0.8; 95% CI: 0.57, 1.14); sex (OR = 0.9; 95% CI: 0.67, 1.33); resident involvement (OR = 1.1; 95% CI: 0.63, 2.0); presentation to an academic centre (OR = 1.4; 95% CI: 0.96, 1.95) or stone size (OR = 1.3; 95% CI: 0.76, 2.06). Conclusion: Management of renal colic with MET is uncommon in this region and practice variation appears driven by physician preference rather than evidence. Practice guidelines with standardized order sets are urgently needed to improve care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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