Introduction: Unrecognized delirium in the ED remains common despite a 3 fold mortality increase for those discharged home. But previous studies have not assessed delirium recognition rate in a multicenter study nor assessed the management plans of ED staff when they fail to recognize delirium. Objectives: To document 1) the rate of delirium recognition by nurses and MDs in a national sample and 2) the intended management plans for patients with unrecognized delirium. Methods: This is a planned sub-study of a randomized clinical trial at 5 EDs in 4 provinces conducted in English and French. We included people ≥ 65 years old. We excluded those with an ED stay < 4 hours, critical illness, visual impairment or from a nursing home. Research assistants (RAs) assessed delirium using the validated Confusion Assessment Method. RAs then asked ED nurses and physicians if the patient had delirium according to their clinical assessment. RAs also asked how confident they were that the patient could be safely discharged home using a 10 point Likert scale. We report proportions and 95% confidence intervals. RAs notified all ED staff of unrecognized CAM + ve patients prior to actual discharge for safety reasons. Results: We recruited 1584 older people; 1496 (92.5%) had complete data. Mean age was 76.5; 49% were female. Nurses performed 1465 delirium assessments. There were 76 CAM + ve patients in our sample (5.2%, 95% CI 4.2 to 6.5%). Nurses recognized delirium in 34/76 (44.7%, 95% CI: 33.3 to 56.6%). MDs assessed 20 CAM + ve patients and recognized the delirium in 10/20 (50.0%, 95% CI: 27.2 to 72.8). Nurses felt that 11/42 patients with unrecognized delirium could be discharged (26.2% 95% CI: 13.9 to 42.0%). Their median confidence in the safety of their plan was 7.0/10. MDs felt that 2/10 patients with unrecognized delirium could be discharged (20.0% 95% CI: 2.5 to 55.0%). Their median confidence in the safety of their plan was 7.5/10. Conclusion: Despite the potential Hawthorne effect raising initial delirium recognition rates above clinicians’ usual practice outside of a study, delirium recognition by both nurses and MDs remains poor in a national sample of ED patients. We also showed that a significant number of these patients could have been discharged with unrecognized delirium. Further research to find novel ways to improve delirium recognition is needed.

Introduction: Acute pain is frequent among patients visiting the emergency department (ED). In addition to the acute discomfort, pain has been linked to adverse events and poorest outcomes in older adults. However, pain is frequently overlooked by emergency clinicians, particularly in older adults. Advanced age has been linked to poor recognition and under treatment of pain. The contribution of ED investigations and procedures to the patient's pain is unknown. This study aims to determine the intensity of the pain induced by the investigations and procedures commonly performed in the ED. Methods: In two EDs, a convenience sample of older adults (≥ 65 years old) with at least two investigations or procedures performed during their ED visit were eligible. Patients were excluded if they were hemodynamically unstable, in palliative care or not oriented in time and space. The pain intensity was assessed at bedside by a research assistant for the following investigations or procedures: blood sampling, intravenous catheter, electrocardiogram, X-rays, computed tomography, beside ultrasound, urinary catheter, cervical collar and prehospital immobilization mattress. The predetermined sample size was 50 pain assessment per investigation or procedure. The pain intensity was assessed using a numerous rating scale (NRS) ranging from 0 (no pain) to 10 (most severe pain), for each investigation or procedure received. NRS results are presented using median (med) and interquartile range (IQR) and classified as followed: no pain (0), mild pain (1-3), moderate pain (4-6) and severe pain (7-10). Results: Between June 2018 and December 2019, 494 patients were screened of which 318 were finally included (exclusion: not oriented (n = 113), refusal (n = 27), palliative care (n = 34), other reasons (n = 12)). The mean age of included patients was 77.8 years old (standard deviation = 8.0), 54.4% were female and 78.6% were living in the community. Only 15 patients (4.7%) were known to have cognitive impairment or dementia and 23 patients (7.2%) were on regular or PRN opioid medication at home. The expected sample size of at least 50 pain score assessment per investigation or procedure was obtained for all interventions with the exception of urinary catheter (n = 23) and immobilization mattress (n = 35). For the other investigations or procedures, the number of pain assessment ranged between 51 (cervical collar) and 231 (blood sampling). All investigations and procedures were associated with a median pain score of 0 with the exception of blood sampling (n = 231, med NRS 1 (IQR 0;3)), intravenous catheter (n = 241, med NRS 1 (IQR 0;4)), urinary catheter (n = 23, med NRS 4 (IQR 1;6)), cervical collar (n = 51, med NRS 5 (IQR 0;8)) immobilisation mattress (n = 35, med NRS 3 (IQR 0;8)). Moderate or severe pain (NRS 4-10) was infrequently reported following most investigations or procedures with the exception of urinary catheter (60.8%), cervical collar (54.9%) and immobilization mattress (48.5%). Cervical collar induced severe pain in 41.8% of the patients. Conclusion: Most investigations and procedures commonly administered in the ED to older adults are associated with no pain or low intensity of pain. Severe pain is also infrequently induced by these interventions for most older adults. However, urinary catheter, cervical collar and immobilization mattress are associated with a higher intensity of pain and more than 40% of patients suffering from severe pain following the application of cervical collar. Considering the potential adverse effects of pain and the lack of evidence-based data to support the use of some interventions such as the cervical collar, the decision to use these interventions should be carefully weighted and could include a shared-decision making process. The generalizability of those findings to older adults with cognitive impairment is unknown. Future studies should focus on circumstances in which these procedures are beneficial to the patient to limit the unnecessary pain associated with their use.

Introduction: The Maximizing Aging Using Volunteer Engagement in the ED (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program and the activities performed with older patients by its volunteers. Methods: The MAUVE + ED program was implemented in the ED (annual census 65,000) of a large academic tertiary hospital in Toronto, Ontario. Volunteers were trained to identify and approach older patients and others at greater risk for adverse outcomes, including poor patient experience, in the ED and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. Results: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median (IQR) time a MAUVE volunteer spent with a patient was 10 (5, 20) minutes, with a range of 1 to 130 minutes. The median (IQR) number of patients seen per shift was 7 (6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). Conclusion: Preliminary data suggest the MAUVE + ED volunteers were able to enrich the experience of older adults and their families/carers in the ED.

Introduction: Participant interviews are often considered the ‘gold standard’ for measuring outcomes in diagnostic and prognostic studies. Participant exposure data are frequently collected during study interviews, but the reliability of this information often remains unknown. The objective of this study was to compare patient-reported medication exposures and outcomes to data extracted from electronic medical records (EMRs) to determine reliability. Methods: This was a secondary data analysis from a prospective observational cohort study enrolling older (≥ 65 years) patients who presented to one of three emergency departments after a fall. After patients had consented to participate in the study, they were asked about their use of antiplatelet and anticoagulation medications (exposures of interest). During follow up, participants were asked if a physician had told them they had bleeding in their head (diagnosis of intracranial hemorrhage). Patient-reported responses were compared to data extracted from a structured EMR review. Trained research assistants extracted medication exposure and outcome data from the hospital EMRs in duplicate for all visits to any hospital within 42 days. Inter-rater agreement was estimated using Cohen's kappa (K) statistics with 95% confidence intervals (CIs). Results: 1275 patients completed study interviews. 1163 (91%) responded to questioning about antiplatelet use and 1159 (91%) to anticoagulant use. Exact agreement between patient reported antiplatelet use compared to EMR review was 77%, with K = 0.50 (95% CI: 0.44 to 0.55). For anticoagulation use, exact agreement was 87%, with K = 0.68 (95% CI: 0.63 to 0.72). 986 (78%) patients had a follow up interview after 42 days. Exact agreement between patient reported intracranial bleeding and EMR review was 95%, with K = 0.30 (95% CI: 0.15 to 0.45). Using the EMR review as the reference standard, the sensitivity and specificity of patient reported intracranial bleeding was 34% (95% CI: 20 to 52%) and 97% (95% CI: 96 to 98%), respectively. Conclusion: In this population of older adults who presented to the ED after a fall, patient reported use of antiplatelet and anticoagulant medications was not a reliable method to identify medication use. Patients who were diagnosed with intracranial bleeding were particularly poor at reporting this diagnosis.

Introduction: Prognostication and disposition among older Emergency Department (ED) patients with suspected infection remains challenging. Frailty is increasingly recognized as a predictor of poor prognosis among critically ill patients, however its association with clinical outcomes among older ED patients with suspected infection is unknown. Methods: We conducted a multicentre prospective cohort study at two tertiary care EDs. We included older ED patients (≥ 75 years) presenting with suspected infection. Frailty at baseline (prior to index illness) was explicitly measured for all patients by the treating physicians using the Clinical Frailty Scale (CFS). We defined frailty as a CFS 5-8. The primary outcome was 30-day mortality. We used multivariable logistic regression to adjust for known confounders. We also compared the prognostic accuracy of frailty against the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) criteria. Results: We enrolled 203 patients, of whom 117 (57.6%) were frail. Frail patients were more likely to develop septic shock (adjusted odds ratio [aOR]: 1.83, 95% confidence interval [CI]: 1.08-2.51) and more likely to die within 30 days of ED presentation (aOR 2.05, 95% CI: 1.02-5.24). Sensitivity for mortality was highest among the CFS (73.1%, 95% CI: 52.2-88.4), as compared to SIRS ≥ 2 (65.4%, 95% CI: 44.3-82.8) or qSOFA ≥ 2 (38.4, 95% CI: 20.2-59.4). Conclusion: Frailty is a highly prevalent prognostic factor that can be used to risk-stratify older ED patients with suspected infection. ED clinicians should consider screening for frailty in order to optimize disposition in this population.

Introduction: Older (age >=65 years) trauma patients suffer increased morbidity and mortality. This is due to under-triage of older trauma victims, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. There are currently no Canadian guidelines for the management of older trauma patients. The objective of this study was to identify modifiers to the prehospital and emergency department (ED) phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study to assess senior-friendly major trauma care modifiers based on national expert consensus. The panel consisted of 24 trauma care providers across Canada, including medical directors, paramedics, emergency physicians, emergency nurses, trauma surgeons and trauma administrators. Following a literature review, we developed an online Delphi survey consisting of 16 trauma care modifiers. Three online survey rounds were distributed and panelists were asked to score items on a 9-point Likert scale. The following predetermined thresholds were used: appropriate (median score 7–9, without disagreement); inappropriate (median score 1–3; without disagreement), and uncertain (any median score with disagreement). The disagreement index (DI) is a method for measuring consensus within groups. Agreement was defined a priori as a DI score <1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panelists. Of 19 trauma care modifiers, the expert panel achieved consensus agreement for 17 items. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate <10 or >20 breaths/minute or needing ventilatory support (DI = 0.24). The ED modifier with the strongest level of agreement was obtaining a 12-lead electrocardiogram following the primary and secondary survey for all older adults (DI = 0.01). Two trauma care modifiers failed to reach consensus agreement: transporting older patients with ground level falls to a trauma centre and activating the trauma team based solely on an age >=65 years. Conclusion: Using a modified Delphi process, an expert panel agreed upon 17 trauma care modifiers for older adults in the prehospital and ED phases of care. These modifiers may improve the delivery of senior-friendly trauma care and should be considered when developing local and national trauma guidelines.

Introduction: Acute psychosis is a disruptive change in mental state that requires the mobilization of significant resources for its immediate treatment and ongoing management in the emergency department (ED). Cannabis-induced psychotic disorder (CIP) is one potential cause; however, the diagnosis may be overlooked due to limited understanding of the etiology of CIP. Methods: This study employed a retrospective cohort analysis of all CIP cases admitted from a tertiary care ED in Edmonton, Alberta between 10/2016 and 10/2018 – the month cannabis was legalized in Canada. Charts were identified based on a most responsible diagnosis of CIP, as defined by ICD-10 code F12.5. Two reviewers abstracted data using a standardized form, which was entered into a database; 10% of charts were analyzed by both reviewers to examine inter-rater reliability. Patients were excluded if there was any documentation of methamphetamine use within the week prior to presentation. Outcomes included management, symptom profile, and length of stay. Results: In total there were 44 cases of CIP identified in 40 unique patients during the two-year period. The largest age group of patients (n = 14, 35%) were between 15-20 years old and the median length of admission was 6 days. A minority of patients (n = 13, 32.5%) had a previous psychiatric diagnosis. A distinct clinical picture evolved during the summation of patient symptoms in the ED with 65% of patients (n = 26) exhibiting persecutory delusions and 52.5% endorsing auditory hallucinations (n = 21). Only four patients were found to have visual hallucinations, three of which also had auditory hallucinations. Most patients (n = 34, 85%) were treated with an antipsychotic medication in the ED and during their time as inpatients, but only 70% of patients were prescribed an antipsychotic medication at the time of discharge (n = 28). Conclusion: This study is the first of its kind describing a cohort of patients with CIP in a Canadian ED setting. The patients presenting to the ED who would later be diagnosed CIP were more likely to be 15-20 years old, experiencing persecutory delusions, and unlikely to be experiencing isolated visual hallucinations. With the recent legalization of cannabis in Canada, further prospective research is required to determine any changes in the characteristics, incidence, and prevalence of CIP, as well as data from other centers to look for any regional differences in the presentation and management of CIP.

Introduction: There are few large-scale studies assessing the true risk of epinephrine use during anaphylaxis in adults. We aimed to assess the demographics, clinical characteristics, and secondary effects of epinephrine treatment and to determine factors associated with major and minor secondary effects associated with epinephrine use among adults with anaphylaxis. Methods: From May 2012 to February 2018, adults presenting to the Hôpital du Sacré-Coeur de Montréal (HSCM) emergency department (ED) with anaphylaxis were recruited prospectively as part of the Cross-Canada Anaphylaxis Registry (C-CARE). Missed cases were identified through a previously validated algorithm. Data were collected on demographics, clinical characteristics, and management of anaphylaxis using a structured chart review. Multivariate logistic regression models were compared to estimate factors associated with side effects of epinephrine administration. Results: Over a 6-year period, 402 adult patients presented to the ED at HSCM with anaphylaxis. The median age was 38 years (Interquartile Range [IQR]: 27, 52) and 40.4% were males. The main trigger for anaphylaxis was food (53.0%). A total of 286 patients (71.1%) received epinephrine treatment, of which 23.9% were treated in the pre-hospital setting, 47.0% received treatment in the ED, and 5.0% received epinephrine in both settings. Among patients treated with epinephrine, major secondary effects were rare (1.4% of patients), including new changes to electrocardiogram, arrhythmia, and neurological symptoms. Minor secondary effects due to epinephrine were reported in 50.0% of patients, mainly inappropriate sinus tachycardia (defined as a rate over 100 beats/minute in 30.1%). Major cardiovascular secondary effects were associated with regular use of beta-blockers (aOR 1.10 [95%CI, 1.02, 1.18]), regular use of ACE-inhibitors (aOR 1.16 [95%CI, 1.07, 1.27]), and receiving more than two doses of epinephrine (aOR 1.09 [95%CI, 1.00, 1.18]). The model was adjusted for age, history of ischemic heart disease, trigger of anaphylaxis, presence of asthma, sex, and reaction severity. Inappropriate sinus tachycardia was more likely in females (aOR 1.18 [95%CI, 1.04, 1.33]) and palpitations, tremors, and psychomotor agitation were more likely in females (aOR 1.09 [95%CI, 1.00, 1.19]) and among those receiving more than two doses of epinephrine (aOR 1.49 [95%CI, 1.14, 1.96]). The models were adjusted for age, regular use of medications, history of ischemic heart disease, triggers of anaphylaxis, presence of asthma, reaction severity, and IV administration of epinephrine. Conclusion: The low rate of occurrence of major secondary effects of epinephrine in the treatment of anaphylaxis in our study demonstrates the overall safety of epinephrine use.

Introduction: The opioid crisis has reached epidemic levels in Canada, driven in large part by prescription drug use. Emergency physicians are frequent prescribers of opioids; therefore, the emergency department (ED) represents an important setting for potential intervention to encourage rational and safe prescribing. The objective of this study was to systematically review the literature on interventions aimed to influence opioid prescribing in the ED. Methods: Electronic searches of Medline and Cochrane were conducted and reference lists were hand-searched. All quantitative studies published in English from 2009 to 2019 were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible studies, the full texts of which were retrieved and assessed for inclusion. Outcomes of interest included opioid prescribing rate (proportion of ED visits resulting in an opioid prescription at discharge), morphine milligram equivalents per prescription and variability among prescribers. Results: The search strategy yielded 797 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 34 potentially relevant studies were retrieved in full text. Of these, 28 studies were included in the review. The majority (26, 92.9%) of studies were based in the United States and two (7.1%) were from Australia. Four (14.3%) were randomized controlled trials. The interventions were classified into six categories: prescribing guidelines (n = 10), regulation/rescheduling of opioids (n = 6), prescribing data transparency (n = 4), education (n = 4), care coordination (n = 3), and electronic medical record changes (n = 1). The majority of interventions reduced the opioid prescribing rate from the ED (21/28, 75.0%), although regulation/rescheduling of opioids had mixed effectiveness, with 3/6 (50%) studies reporting a small increase in the opioid prescribing rate post-intervention. Education had small yet consistent effects on reducing the opioid prescribing rate. Conclusion: A variety of interventions have attempted to improve opioid prescribing from the ED. These interventions include prescribing guidelines, regulation/rescheduling, data transparency, education, care coordination, and electronic medical record changes. The majority of interventions reduced the opioid prescribing rate; however, regulation/rescheduling of opioids demonstrated mixed effectiveness.

Introduction: Canada is in the midst of an opioid crisis. The number of apparent opioid-related deaths between January and March 2018 increased by 44% compared to the same period in 2016. The increasing use of prescription opioids and higher doses of opioids can lead to opioid addiction, toxicity and even death. Opioids are commonly prescribed for low back pain management in the ED, but the variability in opioid-prescribing patterns suggested an opportunity for improvement. Our centre implemented Clinician Performance Indicators (CPI) in 2015. CPIs were reported to each ED physician every 3 months and included the percentage of patients who were prescribed opioids. The intent was to raise awareness of opioid-prescribing patterns at our institution. Therefore, we evaluated opioid-prescribing patterns for patients with low back pain (LBP) before and after the CPI implementation. Methods: Data were obtained retrospectively for patients discharged from the ED from July 2015 to December 2018 with LBP-associated ICD 10 codes. We excluded admitted patients, those with specialist consultations, and patients who left without being seen. The primary outcome was opioid prescribing patterns for patients with LBP before and after CPI implementation. We performed a descriptive analysis of the data and compared the prescribing rates pre-implementation (July-Dec 2015) to post-implementation (July-Dec 2016) following a 6-month wash-out period. Moreover, we analyzed opioid-prescribing patterns over an extended period until December 2018. Results: After the exclusion criteria were applied, 8993 patients were included in the analysis. 53.5% were female and the mean (SD) age was 48.3 (19.78). During the three years of the study period, the percentage of LBP patients who received opioids showed a decreasing trend. Comparison of the pre and post CPI implementation periods showed a decrease in opioid prescriptions (42.0% vs 35.5%, 95%CI 2.9% to 10.2%). There was variation in opioids prescribed at our institution, the most common being hydromorphone (29.9%), followed by acetaminophen-oxycodone (24.2%) and acetaminophen-tramadol (20.0%). Conclusion: The implementation of CPIs positively impacted physicians' opioid-prescribing patterns for patients presenting with LBPs at our institution. Future studies are required to further improve the effectiveness of CPIs in influencing opioid-prescribing patterns.

Introduction: In a busy emergency department (ED), effective communication is integral to the provision of safe medical care. Physicians working in the ED interact with multiple team members including patients, allied healthcare professionals and other physicians, who all need to understand their verbal and written instructions. Our study's objective was to identify and describe communication problems occurring in the ED setting, and how these problems contributed to patient safety events and increased medico-legal risk for physicians. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, medico-legal organization which represented over 97,000 physicians at the time of this study. We conducted a retrospective descriptive analysis where we extracted five years (2013-2017) of CMPA data describing closed medico-legal cases occurring in the ED involving physicians (any specialty) who experienced complaints due to communication issues. We then applied an internal contributing factor framework to identify data themes. Data were summarized using descriptive statistics. Results: We identified 517 eligible cases involving 521 patients (some cases involved >1 patient). We found that 99.8% (520/521) of patients experienced some form of healthcare-related harm in the ED. Specifically, there was poor communication between: the physician and patient or patient's family (202/517, 39.1%); two or more physicians (79/517, 15.3%), and physicians and other healthcare providers (55/517, 10.6%). Inadequate documentation was observed in more than half of the cases (324/517, 62.7%) and poor team communication affected physicians’ decision making process (326/517, 63%) in areas such as deficient assessments, inadequate investigations, failure or delay to attend to the patient, and disposition decisions. Conclusion: Team communication issues are prevalent among physician medico-legal cases occurring in the ED. Efforts to strengthen communication skills may enhance patient safety and reduce medico-legal risk.

Introduction: Recent evidence shows an increase in alcohol-related emergency department (ED) visits among youth. We sought to quantify the impact of ED visits (type and frequency, patient characteristics and resource use) related to alcohol in our centre. Methods: This was a chart review of patients aged 12-24 with alcohol-related ED visits between Sept 2013-Aug 2017. The National Ambulatory Care Reporting System (NACRS) database was searched for visits alcohol related ICD-10 codes. The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) database was also searched using the keyword alcohol. Duplicate visits were removed. Visits were excluded if patients had a history of psychosis, were held in the ED for psychiatric assessment, were homeless, were inmates from a correctional institute, if alcohol use was not mentioned and for complaints of sexual assault/intimate partner violence. Data was abstracted by two reviewers using a standard form with predetermined variables. Differences were resolved with third party adjudication. Interrater reliability of the reviewers was assessed with Kappa scores through duplicate review of 10% of randomly selected charts. A further 10% were assessed by a 3rd reviewer for extraction accuracy. Results: 3,256 ED visits were identified with 777 removed via predefined exclusion criteria. 2,479 visits were reviewed with a male predominance (54.3%). More than half of all patients (50.9%) arrived via ambulance. Assigned CTAS levels were Resuscitation: 1% Emergent: 9.9% Urgent: 48.2% Less Urgent: 35.7% Non-Urgent: 4.2% (missing 1%). The median LOS was 2.9 hrs (IQR 1.8-4.6). All visits were subclassified into mutually exclusive categories: injury (51.8%), acute intoxication (45.1%) and mental health issue (3.2%). Males were more likely to present with injury (62.4% vs 42.6%, p < 0.01). Females were more likely to present with acute intoxication (53.3% vs 46.7%, p <0.01) and mental health issues (59.5% vs 40.5%, P = 0.01). ED resource use was notable: 483 (19.4%) had imaging tests and 1216 (49.1%) had some medical intervention (blood test, fluids or medication). 57 (2.3%) patients were admitted and there was one death from an alcohol related MVC. Conclusion: Alcohol-related ED visits by youth are common in our centre and utilize substantial prehospital and in-hospital resources. Identification of effective harm reduction strategies should be a research priority.

Introduction: Emergency department (ED) buprenorphine/naloxone inductions for opioid use disorder are an effective and safe way to initiate addictions care in the ED. Kelowna General Hospital's ED buprenorphine/naloxone (KEDSS) program was implemented in September 2018 in order to respond to a community need for accessible and evidence-based addictions care. The objective of our program evaluation study was to examine the implementation of the first five months of the KEDSS program through evaluating patient characteristics and service outcomes. Methods: The KEDSS treatment pathway consists of a standardized protocol (pre-printed order set) to facilitate buprenorphine/naloxone induction and stabilization in the acute care setting (ED and inpatient wards) at Kelowna General Hospital, a community academic hospital. All patients referred to the outpatient addictions clinic via the order set during September 2018-January 2019 (the first 5 months) were included in the study population. A retrospective descriptive chart review was completed. Outcome measures included population characteristics (sociodemographic information, clinical characteristics) and service outcomes (number of patients initiated, patient follow-up). Descriptive statistics and bivariate analyses using t-tests or Pearson's χ2 statistic, as appropriate, were conducted to compare the ED-initiated group with the inpatient-initiated group. Results: During the first five months of the KEDSS program, a total of 35 patients (26% female, mean age 36.6 years, 54% homeless) were started on the treatment pathway, 16 (46%) in the ED. Compared to the inpatient-initiated group, the ED-initiated group were less likely to have psychiatric comorbidities (ED 1.0 vs. inpatient 1.5, p = 0.002), require methadone or sustained-release oral morphine (ED 13% vs. inpatient 37%, p = 0.048), and have attended follow-up (ED 56% vs. inpatient 84%, p = 0.004). Conclusion: This study provides a preliminary look at a new opioid agonist therapy (OAT) treatment pathway (KEDSS) at Kelowna General Hospital, and provides insight into the population that is accessing the program. We found that the majority of patients who are started on buprenorphine/naloxone in the ED are seen in follow-up at the addictions clinic. Future work will examine ongoing follow-up and OAT adherence rates in the study population to quantify the program's impact on improving access to addictions treatment within this community hospital setting.

Introduction: One of the most common adverse effects of habitual cannabis use is hyperemesis—recurrent bouts of protracted vomiting, retching and abdominal pain superimposed on a baseline of daily nausea and anorexia. Largely anecdotal evidence supports the use of haloperidol, benzodiazepines or topical capsaicin over traditional antiemetics, yet little is known about the cause or optimal treatment of this newly recognized disorder. We report the results of one of the first clinical trials on so-called cannabis hyperemesis syndrome (NCT03056482). Methods: We approached adults with a working diagnosis of hyperemesis due to cannabis, provided they had ongoing emesis for >2 hours, a cyclic pattern of 3+ episodes in the last 2 years, and near daily use of cannabis by inhalation. We excluded those who were pregnant, deemed unreliable, or using opioids. Subjects provided written consent to be randomized during the index or any subsequent visit to either haloperidol (with a nested randomization to either 0.05 mg/kg or 0.1 mg/kg) or ondansetron 8 mg intravenously in a quadruple-blind fashion, and to be followed for 7 days. The primary outcome was the average reduction from baseline in abdominal pain and nausea (each measured on a 10-cm VAS) at 2 hours. While the original trial design allowed for crossover, the primary analysis used only the first treatment period since fewer than the prespecified threshold of 20% of subjects crossed over. Results: We enrolled 33 subjects, of whom 30 (16 men, 29+/-11 years old, using 1.5+/-0.9 g/day since age 19+/-2 years) were treated at least once (haloperidol 13, ondansetron 17). Haloperidol at either dose was superior to ondansetron (difference 2.3 cm [95%CI 0.6, 4.0]; p = 0.01), with similar improvements in both pain and nausea, as well as less rescue antiemetics (27% vs 61%; p = 0.04), and shorter time to ED departure (3.1+/-1.7 vs 5.6+/-4.5 hours; p = 0.03 Wilcoxon rank sum). There were two (haloperidol) vs six (ondansetron) return visits for ongoing nausea/vomiting, as well as two return visits for acute dystonia, both in the higher dose haloperidol group. Conclusion: Haloperidol is superior to ondansetron for the acute symptomatic treatment of patients with ongoing hyperemesis attributed to habitual cannabis use. The efficacy of this agent over ondansetron provides insight into the mechanism of this new disorder, now almost a daily diagnosis in many Canadian emergency departments.

Introduction: Understanding how homeless patients interact with healthcare systems can be challenging. The nature of the population is such that identifying and following these persons can be severely limited by data. Previous studies have used survey data which relies on self-reporting and selected samples such as those persons admitted to homeless shelters (Gray et al. 2011). Other studies have been able to leverage administrative data but only for selected local geographic areas (Somers et al. 2016, Tompkins et al 2003). It is possible that the current literature has not examined a large proportion of homeless persons and their healthcare use. This is concerning because this population can have higher associated medical costs and greater medical resource utilization especially with regards to psychiatric and emergency department (ED) resources (Tulloch et al. 2012, Forchuk et al, 2015). Methods: Administrative health data (2010 to 2017) is used to analyze ambulatory care records for homeless individuals in Ontario, Canada. Uniquely, we are able to use ED contacts as a way of identifying homeless migrations from region to region within Ontario. Using a network analysis we identify high impact ED nodes and discrete hospital networks where homeless patients congregate. We are also able to more fully characterize this population's demographics, health issues, and disposition from the ED. Results: We provide a more complete understanding of migration patterns for homeless individuals, across Ontario and their concomitant ED use and hospitalizations. The three most frequented regions in Ontario (n = 640,897) were Toronto Central (35.96%), Hamilton Niagara Halimand Brant (8.9%) and Champlain (7.84%). In subsequent visits, the majority of patients presented to different EDs, however a subgroup who always presented to the same site was present. Over the 7 year period, migration between visits occurred most often between urban areas, and increased as a whole. Conclusion: The results of the study allow for the enhancement care coordination for vulnerable populations and enhance the availability and delivery of services for sub-groups of homelessness whose care needs may differ based on migration patterns. Services can be coordinated between jurisdictions for homeless individuals, and appropriate referrals can be made across the health care system. Further evidence is provided for a novel method of mapping migration among the homeless and its associations and effects on ED use.

Introduction: The Emergency Departments (ED) is a gateway to the health care system for many psychiatric patients. As a consequence of hospital administrative factors and overcrowding, admitted psychiatric patients are often boarded in the ED while waiting for an inpatient bed. There is currently a lack of evidence to quantify the effect that ED boarding has on psychiatric patients. The primary objective of this study is to determine whether a patient's length of stay is related to longer ED boarding time. Methods: This study is a retrospective cohort using data from an administrative source, which was obtained from patient records captured in the Sunrise Clinical Manager EMR used across Calgary, Alberta EDs from 2014-2018. A hierarchical Bayesian regression analysis was used to model the several patient-level and hospital-level factors. The mean and variance was defined by the exposure of interest, namely hours in the Emergency Department after admission to psychiatry unit expressed as a continuous variable. An interaction between this exposure and patient-level confounders was used to model the changing effect of a patient's severity in the ED on their boarding time. Results: The median boarding time for patients in our study was 6.6 hours (standard deviation 17.3), while the average was 13.6 hours. Patients who were boarded for greater than 6 hours more frequently required an antipsychotic (37% vs 11%; SMD 0.651), sedative (52% vs 29%; SMD 0.483) or restraints (18% vs. 14%; SMD 0.102). In crude analysis there was no difference in median length of stay for patients that were boarding more than 6 hours compared to those boarded for less than 6 hours (8 days vs 9 days; SMD 0.012).The rate ratio for length of stay is 1.05 with 95% posterior interval 1.04 - 1.06 for each 24 hour increase in boarding time. This means that for each 1 day worth of boarding time, the length of stay (in days) increases 1.05 times (or 0.05 days/day boarding time). Conclusion: Boarding time is associated with a small but absolute increase in length of stay for psychiatric patients. Decreasing boarding time could have ripple effects for ED efficiency and overall patient outcomes.

Introduction: With the transition of Emergency Medicine into competency based medical education (CBME), entrustable professional activities (EPAs) are used to evaluate residents on performed clinical duties. This study aimed to determine if implementing a case-based orientation, designed to increase recognition of available EPAs, into CBME orientation would help residents increase the number of EPAs completed. Methods: We designed an intervention consisting of clinical cases that were reviewed by national EPA experts who identified which EPAs could be assessed from each case. A case-based session was incorporated into the 2019 CBME orientation for The McMaster Emergency Medicine Program. Postgraduate Year (PGY)1 residents read the cases and discussed which EPAs could be obtained with PGY2/faculty facilitators. The number of EPAs completed in the first two blocks of PGY1 was determined from local program data and Student's t-test was used to compare averages between cohorts. Results: We analyzed data from 22 trainees (7 in 2017, 8 in 2018, and 7 in 2019). In the first two blocks of PGY1, the intervention cohort (2019) had a significantly higher average number of EPAs completed per trainee (47.4 [SD 11.8]) than the historical cohort (25.3 [SD 6.7]) (p < 0.001) (Cohen's d = 2.3). No significant difference existed in the number EPAs obtained between the 2017/2018 cohorts, with averages of 24.3 [SD 6.8] and 26.1 [SD 7.0] per trainee respectively (p = 0.6). Conclusion: Implementation of a case-based orientation led by CBME-experienced facilitators nearly doubled the EPA acquisition rate of our PGY1s. The consistent EPA acquisition by the 2017/2018 cohorts suggest that the post-intervention increase was not solely due to developed familiarity with the CBME curriculum.

Introduction: 2018 data from the Canadian Medical Association website shows that of practicing emergency physicians country-wide, only 31% were female. While there are some studies that examine the number and proportion of Canadian female applicants applying to surgical specialties, there are very few studies that are specific to emergency medicine (EM), and none that are Canadian in scope. Given the changing gender ratio of graduating medical students in Canada, the primary objective of this study is to assess the mean proportion and trends in proportion of females who applied and matched to English-language Canadian EM programs including Canadian College of Family Physicians emergency medicine certificate (CCFP-EM) and Fellow of the Royal College of Physicians of Canada emergency medicine (FRCPC-EM), family medicine (CCFP) programs, and all specialties combined. Methods: A retrospective data analysis on residency match results from 2013-2019 inclusively was performed. Data was accessed through a freedom of information request from the Canadian resident matching service (CaRMS). The mean proportions and trends in the proportions of females applying and matching to CCFP-EM, FRCPC-EM, CCFP, and all specialties were computed. Cochrane-Armitage trend of test was used for analysis. Results: From 2013-2019, the mean (SD) percentage of females who applied and matched respectively were as follows: CCFP-EM [44.4 (3.5);46.0(4.5)]; FRCPC-EM [41.3(4.1);44.0 (4.5], CCFP [56.5(1.3);61.0(1.9)], all specialties [54.0(1.1);55.5(0.9)]. There was a significant increase in the proportion of female applying to the FRCPC-EM (p < 0.0001), CCFP (p = 0.0002), and all disciplines (p = 0.0013). There was no significant change in the proportion of females applying for the CCFP-EM program (p = 0.6435). Conclusion: Our study shows that there is an increasing trend in the percentage of female applicants in all programs except the CCFP-EM program, where it remained statistically the same over time. There was a consistent percentage of applied versus matched female applicants over time for both CCFP-EM and FRCPC-EM programs. However, the percentage of females applying or matching to both CCFP-EM and FRCPC-EM programs remained less than 50%. Further research could focus on evaluating reasons for program choice, in order to further increase the percentage of female medical students and residents applying and matching to both emergency medicine programs.

Introduction: The Ottawa Emergency Department Shift Observation Tool (O-EDShOT) was recently developed to assess a resident's ability to safely run an ED shift and is supported by multiple sources of validity evidence. The O-EDShOT uses entrustability scales, which reflect the degree of supervision required for a given task. It was found to discriminate between learners of different levels, and to differentiate between residents who were rated as able to safely run the shift and those who were not. In June 2018 we replaced norm-based daily encounter cards (DECs) with the O-EDShOT. With the ideal assessment tool, most of the score variability would be explained by variability in learners’ performances. In reality, however, much of the observed variability is explained by other factors. The purpose of this study is to determine what proportion of total score variability is accounted for by learner variability when using norm-based DECs vs the O-EDShOT. Methods: This was a prospective pre-/post-implementation study, including all daily assessments completed between July 2017 and June 2019 at The Ottawa Hospital ED. A generalizability analysis (G study) was performed to determine what proportion of total score variability is accounted for by the various factors in this study (learner, rater, form, pgy level) for both the pre- and post- implementation phases. We collected 12 months of data for each phase, because we estimated that 6-12 months would be required to observe a measurable increase in entrustment scale scores within a learner. Results: A total of 3908 and 3679 assessments were completed by 99 and 116 assessors in the pre- and post- implementation phases respectively. Our G study revealed that 21% of total score variance was explained by a combination of post-graduate year (PGY) level and the individual learner in the pre-implementation phase, compared to 59% in the post-implementation phase. An average of 51 vs 27 forms/learner are required to achieve a reliability of 0.80 in the pre- and post-implementation phases respectively. Conclusion: A significantly greater proportion of total score variability is explained by variability in learners’ performances with the O-EDShOT compared to norm-based DECs. The O-EDShOT also requires fewer assessments to generate a reliable estimate of the learner's ability. This study suggests that the O-EDShOT is a more useful assessment tool than norm-based DECs, and could be adopted in other emergency medicine training programs.

Introduction: Task interruptions are reportedly frequent disturbances for emergency physicians performing advanced life support (ALS). The aim of this study was to evaluate the benefit of adding task interruptions in ALS simulated training session. Methods: We conducted a multi centered randomized controlled trial in four emergency departments of a university hospital in Paris, France. Each emergency team included one resident, one nurse and one emergency physician. The teams were randomized for the nature of their training session: control (without interruption) or realistic (with interruptions). The interruption consisted of an interfering family member speaking a foreign language, and of repetitive phone calls during ALS. After the first training session, teams were evaluated on a second realistic session with task interruptions. The primary outcome was non-technical skills assessed with the TEAM score during this evaluation session. We also measured the no flow time, and the Cardiff score, which reflects the quality of ALS: including chest compression depth and rate, no flow time. Results: On a total of 23 included teams, 12 had a control training session and 11 with task interruptions. Baseline characteristics and TEAM score were similar between the two groups (Mean difference: 3,3 [-2,2; 8,9]; p = 0,26). During the evaluation session, the TEAM score was lower for “realistic” teams (mean difference -8 [95% confidence interval -13; -3]). We also report a higher no flow time and similar overall Cardiff score. Conclusion: In this simulated ALS study, the presence of disturbances during simulation seemed to worsen the quality of training. This study highlights the negative consequences of task interruptions in emergency medicine.