Introduction: Non-medical cannabis recently became legal on October 18th, 2018 to Canadian adults. The impact of legalization on Emergency Departments (EDs) has been identified as a major concern. The study objective was to identify changes in cannabis-related ED visits and changes in co-existing diagnoses associated with cannabis-related ED visits pre- and post-legalization for the entire urban population of Alberta. Urban Alberta was defined as Calgary and Edmonton, inclusive of Sherwood Park and St. Albert given the proximity of some Edmontonians to their EDs) encompassing 12 adult EDs and 2 pediatric EDs. Methods: Retrospective data was collected from the National Ambulatory Care Reporting System, and from the HealthLink and the Alberta Poison and Drug Information Service (PADIS) public telehealth call databases. An interrupted time-series analysis was completed via segmented regression calculation in addition to incident rate and relative risk ratio calculation for the pre- and post-legalization periods to identify both differences among the entire urban Alberta population and differences among individuals presenting to the ED. Data was collected from October 1st, 2013 up to July 31st, 2019 for ED visits and was adjusted for natural population increase using quarterly reports from the Government of Alberta. Results: The sample included 11 770 pre-legalization cannabis-related visits, and 2962 post-legalization visits. Volumes of ED visits for cannabis-related harms were found to increase post-legalization within urban EDs (IRR 1.45, 95% CI 1.39, 1.51; absolute level change: 43.48 visits per month in urban Alberta, 95% CI 26.52, 60.43), and for PADIS calls (IRR 1.87, 95% CI 1.55, 2.37; absolute level change: 4.02 calls per month in Alberta, 95% CI 0.11, 7.94). The increase in visits to EDs equates to an increase of 2.72 visits per month, per ED. Lastly, increases were observed for cannabinoid hyperemesis (RR 1.23, 95% CI 1.10, 1.36), unintentional ingestion (RR 1.48, 95% CI 1.34, 1.62), and in individuals leaving the ED pre-treatment (RR 1.28, 95% CI 1.08, 1.49). Decreases were observed for coingestant use (RR 0.77, 95% CI 0.73, 0.81) and hospital admissions (RR 0.88, 95% CI 0.80, 0.96). Conclusion: Overall, national legalization of cannabis appears to be correlated with a small increase in cannabis-related ED visits and poison control calls. Post-legalization, fewer patients are being admitted, though cannabinoid hyperemesis appears to be on the rise.

Introduction: As the population of Canadian cities grows, public policy planners frequently base predictions of future demand on population trends. We aimed to discover the relationship between demographically defined ED visit rate (EDVR) trends in an academic ED with corresponding population trends in the catchment area. Methods: We used administrative data to conduct a retrospective cohort time series to analyze per capita EDVR trends based on CTAS, age, gender and housing status for the period 2006-2015. These were adjusted for population growth using age-gender standardized rates from 2011 census data. All EDVR and Standardized estimates were extrapolated for 100,000 population. Results: There were 646 731 visits during the study period, increasing by 25.6% from 56 757 in 2006 to 71 289 in 2015, with an annual incremental linear trend of 1893/year (CI:1593-2192). The highest CTAS2 EDVR increase, 521/year, (95%CI: 433-608) was by non-homeless patients older than 49. CTAS2 visits and the rate in all non-homeless patients increased by 335/year, (95% CI 280-391), while homeless patients less than 30 showed the highest CTAS2 EDVR annual rate incremease (1183/year, CI:1448-2218). From 2008-2015, the annual linear per capita CTAS5 EDVR declined by 121/year (CI:79-163). The population of adults in Halifax increased by1.2%/yr with a linear trend of 4149/year (CI:4012-4287). The highest linear increasing trend was for those older than 49 (2604/year CI:2494-2714), followed by 30-50-year old group (1223/year, CI:1138-1309) with the lowest trend for those aged less than 30 (322/year,CI:170-473). Standardized and non-standardized rate decline (CTAS5) and incline (CTAS2) were statistically similar and were not influenced by population changes. The population older than 49 increased by 38% over the 10 year period, whereas the CTAS2 visit change increased by 250%. If the CTAS2 EDVR trend continues, this rate in 2027 will double that of 2015, even if the population in the catchment area remains stable. Conclusion: EDVR trends show an increase in CTAS2 visits driven chiefly by older patients. This trend exceeds the trend suggested by Canadian Foundation for Healthcare Improvement and is significantly more than predicted by population demographic changes. Healthcare administrators will need to bear these disparities in mind as they prepare for future ED capabilities.

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.

Introduction: Electrocardiogram (ECG) diagnosis of acute coronary occlusion has been broadening in recent years, from classic ST-Elevation Myocardial Infarction (STEMI) criteria to STEMI-equivalents and rules for subtle occlusions. However, there is no quality metric focused on emergency physicians’ decision-making. We hypothesized that the time from initial emergency department (ED) ECG to activation of Code STEMI could quantify diagnostic delay associated with automated interpretation, classic STEMI criteria, and other signs of occlusion. Methods: This multi-centre retrospective study reviewed all ED Code STEMI patients with confirmed culprit lesions from two urban academic EDs over a three-year period (Jan 2016 to Dec 2018). We reviewed charts to calculate ECG-to-Activation (ETA) time, measured from the time stamp on the initial ED ECG to the time a Code STEMI was activated (based on the hospital call centre log). We examined ECGs to determine: 1) if automated computer interpretation labelled “STEMI” or not; and 2) whether they met classic STEMI criteria, STEMI-equivalent patterns, or rules for subtle occlusion, based on a priori criteria from published guidelines or studies. All ECGs were reviewed by the lead author (JTTM) and those not obviously meeting classic STEMI criteria were independently reviewed by the other author. Results: There were 180 Code STEMIs from the ED with culprit lesions, including 177 with complete information. Average ETA time was 46.5 minutes (95% Confidence Interval [CI] 36.3-56.7min). Automated interpretation labelled 55.4% of initial ECGs as “STEMI” (ETA 13.9 min, 95%CI 9.8-18.0min), and 44.6% not as “STEMI” (ETA 86.9min, 95%CI 67.9-105.9min). Initial ECGs included 62.1% with classic STEMI criteria (ETA 17.3min, 95%CI 12.8-21.8min), 11.3% with STEMI-equivalents (ETA 49.5min, 95%CI 29.5-69.5min), 18.1% with subtle occlusions (ETA 118.3min, 95%CI 81.5-155.1min) and 8.5% with no initial sign of occlusion (ETA 102.9min, 95%CI 53.9-151.9min). Inter-rater reliability was very good (Cohen's kappa 0.84). Conclusion: Over 90% of Code STEMI patients with culprit lesions had initial ECGs diagnostic of acute coronary occlusion, but automated interpretation and classic STEMI criteria only identified 55.4% and 62.1%, respectively. STEMI-equivalents and subtle occlusions were associated with significant diagnostic delays. ETA time can serve as a quality metric for emergency physicians and may help guide ED quality improvement initiatives.

Introduction: Wide variability exists in emergency department (ED) syncope management. The Canadian Syncope Risk Score (CSRS) was derived and validated to predict the probability of 30-day serious outcomes after ED disposition. The objective was to identify barriers and facilitators among physicians for CSRS use to stratify risk and guide disposition decisions Methods: We conducted semi-structured interviews with physicians involved in ED syncope care at 8 Canadian sites. We used purposive sampling, contacting ED physicians, cardiologists, internists, and hospitalists until theme saturation was reached. Interview questions were designed to understand whether the CSRS recommendations are consistent with current practice, barriers and facilitators for application into practice, and intention for future CSRS use. Interviews were conducted via telephone or videoconference. Two independent raters coded interviews using an inductive approach to identify themes, with discrepancies resolved through consensus. Our methods were consistent with the Knowledge to Action Framework, which highlights the need to assess barriers and facilitators for knowledge use and for adapting new interventions into local contexts. Results: We interviewed 14 ED physicians, 7 cardiologists, and 10 hospitalists/internists across 8 sites. All physicians reported the use of electrocardiograms for patients with syncope, a key component in the CSRS criteria. Almost all physicians reported that the low risk recommendation (discharge without specific follow-up) was consistent with current practice, while less consistency was seen for moderate (15 days outpatient monitoring) and high risk recommendations (outpatient monitoring and/or admission). Key barriers to following the CSRS included a lack of access to outpatient monitoring and uncertainty over timely follow-up care. Other barriers included patient/family concerns, social factors, and necessary bloodwork. Facilitators included assisting with patient education, reassurance of their clinical gestalt, and optimal patient factors (e.g. reliability to return, support at home, few comorbidities). Conclusion: Physicians are receptive to using the CSRS tool for risk stratification and decision support. Implementation should address identified barriers, and adaptation to local settings may involve modifying the recommended clinical actions based on local resources and feasibility.

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias managed in the emergency department (ED). Equipoise in cardioversion strategies for patients with recent onset AFF contributes to observed practice variation. Using administrative data, the objective of this study was to explore the pattern of practice and the comparative effectiveness (outcomes and costs) between Shock-First and Drug-Shock approaches in AFF. Methods: Adult patients >17 years of age with AFF from one academic Canadian hospital ED were eligible. Using administrative data linkage among the National Ambulatory Care Record System, provincial practitioner claims data repository and a local hospital pharmacy database, patients who received treatment with procainamide and/or electrical cardioversion for AFF were identified. Outcomes including disposition, length of stay, revisit within 72 hours and 30-days, and ED costs were analyzed over a seven-year period. Categorical variables are reported as percentages. Continuous variables are reported as median and interquartile range (IQR). Univariate and multivariate logistic regression analyses were completed and reported as odds ratios (OR) and 95% confidence intervals (CI). Results: Overall, 5,372 patients were identified with AFF; the median age was 70 years and 55% were male. The majority of patients had chronic or secondary AFF; however, in 1687 (31%) cardioversion options were employed for presumed were recent onset AFF. A Shock-First strategy was most common (1379 {82%}); 308 (18%) received a Drug-Shock approach. Discharge time was 33 minutes (95% CI: 4–63) longer in the Drug-Shock approach compared to the Shock-First approach. Hospital admissions were higher (OR = 2.33; 95% CI: 1.68, 3.24) and revisits within 30-days were lower (OR = 0.74; 95% CI: 0.54, 0.95) in the Drug-Shock group. The Shock-First strategy demonstrated marginally higher costs (median = $106 CND; 95% CI: $68.89, $144.40) in adjusted analyses. Conclusion: In patients with acute AFF, when cardioversion was attempted, a Shock-First strategy was employed 80% of the time and resulted in shorter ED length of stay and lower hospitalization; however, higher costs and ED revisits within 30-days were observed. Many factors, including physician and/or patient preferences, influence ED decision-making in patients with AFF and understanding the factors influencing these decisions requires further attention.

Introduction: Despite improvements in the recognition of asthma among the pediatric population and the use of preventative therapies, rates of emergency department (ED) visits and hospitalizations remain high, leading one to question how these acute health care visits for asthma can be further avoided. In this study, we aimed to identify predictors of future repeat acute care visits among children and adolescents who had already received ‘best practice’ discharge treatments and instructions during their first asthma ED visit. Methods: We performed a retrospective single center cohort study of all children ages 1-17 years presenting to the ED at the Children's Hospital of Eastern Ontario in Ottawa, Canada for an acute asthma exacerbation during a 1-year time frame between September 1, 2014 – August 31, 2015. Only children with no prior ED asthma visit and documentation of receipt of a prescription for inhaled corticosteroids and/or a written asthma action plan were included. Multivariable logistic regression was performed to identify predictors of repeat future asthma ED visit or hospitalization in the year following the first ED visit. Results: We identified 909 children with an eligible ED visit during the study period, of whom 24% had a repeat asthma ED visit or hospitalization within the subsequent 1 year. Predictors of repeat acute asthma visits included having a nut allergy (OR 1.76, 95% CI: 1.15, 2.70), higher severity symptoms at triage (OR 2.04, 95% CI: 1.23, 3.39), a primary care physician (OR 2.23, 95% CI: 1.26, 3.93), or a prior history of asthma (OR 1.53, 95% CI: 1.03, 2.28). Conclusion: In children and adolescents with repeat asthma ED visits and hospitalizations despite having received ‘best practice’ asthma discharge management at their first ED visit, factors such as having an allergy to nuts, higher severity symptoms at presentation, a prior history of asthma, and having a primary care provider may be used to identify these more high-risk children and adolescents. Such parameters can be used practically to target and apply more intensive preventative interventions to those most in need at the first ED visit, in order to prevent future return visits.

Introduction: Renal colic is among the most painful conditions that patients experience. The main outcome determinants for patients with renal colic are stone size, location and hydronephrosis; however, little is known about the association of pain with these parameters. Our objective was to determine whether more severe pain is associated with larger stones, more proximal stones or more severe hydronephrosis, findings that might suggest the need for advanced imaging, hospitalization or early intervention. Methods: We used administrative data and structured chart review to study all adult emergency department (ED) patients in two cities with a renal colic diagnosis over one-year. Patients with missing imaging results or pain scores were excluded. Triage nurses recorded numeric rating scale (NRS) pain scores on arrival. We stratified patients into mild (NRS <4), moderate (NRS 4-7) and severe (NRS 8-10) pain groups, as per CTAS guidelines. Stone size (mm) and location (proximal, middle, distal ureter, or renal) were abstracted from imaging reports, while index admissions were determined from hospital discharge abstracts. We used multivariable linear regression to determine the association of arrival pain with stone characteristics and hydronephrosis severity (primary outcome), and we used multivariable logistic regression to determine the association of pain with index hospitalization (secondary outcome). We also performed a stratified analysis looking at ureteral vs. kidney (intrarenal) stones. Results: We studied 1053 patients, 66% male, with a mean age of 48 years. After controlling for patient and disease characteristics, we found no significant association between pain severity and stone size (b=−0.0004; 95%CI = -0.0015, 0.0008) or stone location (b = 0.0045; 95%CI: -0.020, 0.029). Nor did we find an association between pain and hydronephrosis severity (b = 0.016; 95%CI: -0.053, 0.022, p = 0.418). Stratified analyses using a Bonferroni correction for multiple comparisons revealed the same absence of associations in the kidney and ureteral stone subgroups. Arrival pain did not predict index admission (OR = 0.82, 95% CI: 0.59, 1.16). Conclusion: Arrival pain scores are not associated with stone size, stone location or hydronephrosis severity, and do not predict index visit hospitalization in ED patients with renal colic. Severe pain should motivate efforts to minimize treatment delays, but do not suggest the need to modify advanced imaging or admission decisions.

Introduction: Buprenorphine/naloxone (buprenorphine) has proven to be a life-saving intervention amidst the ongoing opioid epidemic in Canada. Research has shown benefits to initiating buprenorphine from the emergency department (ED) including improved treatment retention, systemic health care savings and fewer drug-related visits to the ED. Despite this, there has been little to no uptake of this evidence-based practice in our department. This qualitative study aimed to determine the local barriers and potential solutions to initiating buprenorphine in the ED and gain an understanding of physician attitudes and behaviours regarding harm reduction care and opioid use disorder management. Methods: ED physicians at a midsize Atlantic hospital were recruited by convenience sampling to participate in semi-structured privately conducted interviews. Audio recordings were transcribed verbatim and de-identified transcripts were uploaded to NVivo 12 plus for concept driven and inductive coding and a hierarchy of open, axial and selective coding was employed. Transcripts were independently reviewed by a local qualitative research expert and themes were compared for similarity to limit bias. Interview saturation was reached after 7 interviews. Results: Emergent themes included a narrow scope of harm reduction care that primarily focused on abstinence-based therapies and a multitude of biases including feelings of deception, fear of diversion, feeling buprenorphine induction was too time consuming for the ED and differentiating patients with opioid use disorder from ‘medically ill’ patients. Several barriers and proposed solutions to initiating buprenorphine from the ED were elicited including lack of training and need for formal education, poor familiarity with buprenorphine, the need for an algorithm and community bridge program and formal supports such as an addictions consult team for the ED. Conclusion: This study elicited several opportunities for improved care for patients with addictions presenting to our ED. Future education will focus on harm reduction care, specifically strategies for managing patients desiring to continue to use substances. Education will focus on addressing the multitude of biases elicited and dispelling common myths. A locally informed buprenorphine pathway will be developed. In future, this study may be used to advocate for improved formal supports for our department including an addictions consult team.

Introduction: The FAST exam – Focused Assessment with Sonography in Trauma - is a rapid test using ultrasound to identify sonographic evidence of hemorrhage within the abdomen. In the prehospital setting, the information from a FAST examination can help triage patients, direct patients to the most appropriate facilities, assist with management strategies and potentially expedite time to definitive intervention. Few studies examine the accuracy of paramedic-only-performed FAST examinations. However, despite the potential benefits to the Canadian prehospital system, a potential barrier to implementation is the tremendous financial and operational burden if paramedics require prolonged ultrasound training courses. In this study, we conducted a double-blinded observational study comparing the accuracy of paramedic-performed FAST versus physician-performed tests on a sonographic Phantom, after a one-hour didactic training session. Methods: The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model. The mannequin utilized in this study was a realistic model of a human torso where fluid could be injected into the abdomen to create a realistic ultrasound image of abdominal free fluid. Participants were required to scan the mannequin twice, once with 300 mL of fluid instilled and once with the abdomen free of fluid. Participants were blinded to the status of hemoperitoneum. The primary outcome of the study was accuracy rate of FAST examination by paramedics compared to emergency room physicians. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. Total scan time was reported using means, standard deviations and 95% CIs and was compared between groups using standard t-test. Results: Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were ultrasound-naive whereas the emergency physicians had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups 85.6% and 87.5% (Δ1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. Total scan time differed between groups but did not reach statistical significance. Paramedics took longer to complete the FAST examination with a mean (SD) time to complete the two scans of 10.35 (3.43) minutes compared to 7.34 (2.74) minutes for physicians, (Δ3.01 minutes 95%CI -0.97 to 7.00, p = 0.13). Conclusion: This study determined that critical care paramedics were able use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of ultrasound in prehospital programs to determine the most appropriate transport destination and aid in the triage of trauma patients while limiting the financial and logistical burden of ultrasound training.

Introduction: Suicidal jumps from bridges into water are a unique blunt trauma mechanism. Impact into water produces substantial variation in injuries as compared to falls onto hard surfaces. Outcomes can be further complicated by submersion injuries. We identified cases through a multi-agency review in order to analyze injury patterns seen in EDs. Methods: Cases in British Columbia's Lower Mainland of jumps from bridges >12m into water between 2006 and 2017 were identified by retrospective review of Coast Guard and Police records. Records pertaining to identified incidents were located in ambulance and then hospital records. This multi-agency approach was necessary to generate a comprehensive case series, as case identification was not possible at the hospital level. Patient hospital charts were abstracted and injury incidence rates were analyzed. Results: Records were available for 41 of 52 patients. The population was 63% (26/41) male, median age 37 (IQR 29-48). Thirty-two cases were admitted to hospital, seven were deceased in the ED, one was discharged, and disposition is unknown for one. Most patients (85%) presented to Level One trauma centers. Bridge heights ranged from 15m to 70m; the mean fall height was 40.1m. Pulmonary injuries were nearly universal, including pneumothorax (51%), haemothorax (22%), and pulmonary infiltrate (34%). The primary cardiovascular concern was cardiac arrhythmia (51%). A quarter of cases had intraabdominal lacerations or ruptures (27%). Vertebral fractures at all levels were frequent (59%), although there was only one case each of cord transection and contusion. Neurological injuries were rare; 59% of patients presented to the ED with GCS ≥14 and the incidence of intracranial bleeding was low (7%). Rib fractures were commonly reported (37%) along with other fractures (32%). Body temperature was reported in 24 cases with 3 reports of moderate and 6 reports of mild hypothermia. Conclusion: This case series is the first to characterize injury patterns of jumps from bridges into water in Canada. Patterns are similar to reports in the literature from other countries. However, we found lower injury severity, and higher incidences of spinal fractures and cardiac arrhythmias. The low injury severity reflects the survivorship bias inherent to the sample: data was only obtained from patients who survived to be assessed the ED. These results suggest that patients with this mechanism of injury should be treated for both suspected trauma and cold-water immersion injuries.

Introduction: This was a prospective observational study involving a convenience sample of low-risk trauma patients presenting to a Level 1 Trauma Centre under spinal motion restriction (SMR). To our knowledge no prior studies have objectively measured head-neck (H-N) motion in trauma patients with suspected spine injuries during emergency department (ED) care. The goal was to establish the feasibility of deploying non-invasive motion sensors on trauma patients in the ED and to provide initial estimates for H-N kinematics under SMR during different phases of treatment. Methods: Low-risk adult patients treated by Winnipeg Fire Paramedic Service who sustained non-life threatening trauma with the potential for spine injury were eligible for inclusion. Participants received usual pre-hospital care; application of spine board and/or cervical collar, as determined by local practice protocol. Inertial measurement units (IMUs) were placed on participant's forehead, sternum and stretcher upon arrival to the ED. Data was collected during three phases of care: patient handling (log rolls, transfers, clothing removal); stretcher movement (to imaging, etc); stretcher stationary. IMUs were removed upon disposition decision by the attending physician. IMUs yielded data on H-N motion in terms of linear acceleration (resultant) and angular displacement (rotation + flexion-extension + side-flexion = total). Peak (M +/- SE) displacements and accelerations are reported, with comparisons across treatment phases using repeated measures ANOVA. Results: Eleven patients were enrolled in the study (age: 49 +/- 16 years; Injury Severity Score 13.4 +/- 9.9; female = 2). Substantial H-N motion was observed during ED care. Total H-N displacement (28.6 +/- 3.6 deg) and acceleration (7.8 +/- 1.0 m/s2) were higher during patient handling compared to stretcher moving (13.0 +/- 2.5 deg; 4.6 +/- 0.9 m/s2; p < .05) but not while the stretcher was stationary (18.9 +/- 3.4 deg; 5.4 +/- 1.2 m/s2; p > .06). Similar differences were detected for side-flexion and flexion-extension (p < .05), with peak displacements of 11.4+/-1.5 deg and 14.6 +/- 2.2 deg during patient handling, respectively. Conclusion: IMU use on trauma patients safely described H-N motion kinematics in a small sample of patients with different spectrums of illness during their care in the ED. Future studies utilizing IMUs could inform ED spine motion restriction protocols and compare movement of patients in specific subsets (intoxicated, spinal tenderness, injury severity etc.).

Introduction: Emergency department (ED) opioid prescribing has been linked to long-term use and dependence. Anecdotally, significant opioid practice variability exists between physicians and institutions, but this is poorly defined. Our objective was to collate and analyze multicenter data looking at predictors of ED opioid use and to identify potential areas for opioid stewardship. Methods: We linked administrative and computerized physician order entry (CPOE) data from all four ED's within our municipality over a one-year period. Eligible patients included those with a Canadian Triage and Acuity Scale (CTAS) pain complaint or an arrival numeric rating scale (NRS) pain score of greater than 3/10. Patients with missing demographic or chief complaint data were excluded. Multiple imputation was used for missing NRS pain scores. We performed descriptive analyses of opioid-treated and non-treated patients, followed by a multivariable logistic regression to identify predictors of ED opioid administration. Results: A total of 129,547 patients were studied. The mean age was 47.4 years and 55.4% were female. The median pain score was 6.6 in the no-opioid group and 8 in the opioid group. The most common pain categories were abdominal pain (23%), trauma (18.2%) and chest pain (15.3%). Overall, opioids were prescribed to 34% of patients. The most common CTAS score was CTAS 3 (44%), CTAS 1-2 42%) and CTAS 4-5 (13.9%). Multivariable predictors of opioid-use included the need for admission (adjusted OR 6.57; CI = 6.34-6.79), NRS pain score (aOR 1.24 per unit increase, CI 1.23-1.25), higher numerical CTAS score (aOR 0.89 per unit increase, CI 0.87-0.91), and chief complaints of back (aOR 7.69, CI 7.1-8.1), abdominal (aOR 5.9, CI 5.6-6.2), and flank pain (OR 3.8, CI 3.5-4). Oral opioids were prescribed in 39.8% of back pain presentations and 18.5% received IV opioids. Increasing age was a predictor but sex was not. There were significant institutional differences in opioid prescribing rates, with Hospital B being the least likely to prescribe opioids (aOR 0.82, CI 0.80-0.85) followed by Hospital C (aOR 0.83, CI 0.79-0.86) compared to the reference standard of Hospital A. Hospital D was most likely to prescribe opioids (aOR 1.32, CI 1.27-1.37). Conclusion: Predictors of ED opioid use were characterized using multicenter administrative data. Future research should seek to describe the physician- and site-level factors driving regional variation in opioid-based pain treatment.

Introduction: The oral case presentation is recognized as a core educational and patient care activity but has not been well studied in the emergency setting. The objectives of this study are: 1) to develop a competency-based assessment tool to formally evaluate the emergency medicine oral case presentation (EM-OCP) competency of medical students and ‘transition to discipline’ residents, and 2) to develop, implement and evaluate a curriculum to enhance oral case presentation (OCP) communication skills in the emergency medicine (EM) setting. Methods: Using data from a literature review, a Canadian Association of Emergency Physicians national survey, and local focus groups, the authors designed an OCP framework, blended learning curriculum, and EM-OCP assessment tool. Ninety-six clerkship students were randomly assigned to receive either the control, the standard clerkship curriculum, or intervention, the blended learning curriculum. At the beginning of their emergency medicine rotation, learners completed a pre-test using a standardized patient (SP) case to assess their baseline OCP skills. The intervention group then completed the EM-OCP curriculum. All students completed post-tests with a different SP at the end of the six-week EM rotation. Audio-recordings of pre and post-tests were evaluated using the assessment tool by two blinded evaluators. Results: Using the Kruskal-Wallis test, all students demonstrated improvement in EM-OCP skills between their pre-test and post-test, however, those who received the blended learning curriculum showed significantly greater improvement in synthesis of information (p = 0.044), management (p = 0.006) and overall entrustment decision score (p = 0.000). Conclusion: Implementation of a novel EM-OCP curriculum resulted in more effective communication and higher entrustment scores. This curriculum could improve OCP performance not only in emergency medicine settings but also across specialties where medical students and residents must manage critical patients.

Introduction: In 2018, Canadian postgraduate specialist Emergency Medicine (EM) programs began implementing a competency-based medical education (CBME) assessment system. To support improvement of this assessment program, we sought to evaluate its short-term educational outcomes nationally and within individual programs. Methods: Program-level data from the 2018 resident cohort were amalgamated and analyzed. The number of Entrustable Professional Activity (EPA) assessments (overall and for each EPA) and the timing of resident promotion through program stages was compared between programs and to the guidelines provided by the national EM specialty committee. Total EPA observations from each program were correlated with the number of EM and pediatric EM rotations. Results: Data from 15 of 17 (88.2%) EM programs containing 9,842 EPA observations from 68 of the 77 (88.3%) Canadian EM specialist residents in the 2018 cohort were analyzed. The average number of EPAs observed per resident in each program varied from 92.5 to 229.6 and correlated strongly with the number of blocks spent on EM and pediatric EM (r = 0.83, p < 0.001). Relative to the guidelines outlined by the specialty committee, residents were promoted later than expected and with fewer EPA observations than suggested. Conclusion: We present a new approach to the amalgamation of national and program-level assessment data. There was demonstrable variation in both EPA-based assessment numbers and promotion timelines between programs and with national guidelines. This evaluation data will inform the revision of local programs and national guidelines and serve as a starting point for further reaching outcome evaluation. This process could be replicated by other national assessment programs.

Introduction: Participation in Global Health (GH) electives can improve resourcefulness, cultural and ethical insight, and personal development. Risks to trainees, hosts and institutions may be minimized through pre-departure and post-elective training. In 2016 such training was mandatory in only 3 Canadian residency programs, however there is no published data specific to Canadian Emergency Medicine (EM) programs. This study sought to identify current GH elective requirements and related perceived gaps among Royal College EM programs. Methods: We conducted two cross-sectional surveys in 2019 (one each for Royal College EM PDs and residents) via email regarding training requirements for GH electives. Additionally, a survey link was distributed in the CAEP EM resident newsletter. We also contacted university PGME and/or global health offices to understand and collate university-wide requirements and resources. Results: Nine PDs responded, with 78% reporting having 1-5 residents participate in GH electives yearly. Many PDs were unsure of the requirements surrounding GH electives; two reported that pre-departure training was required, while none reported requiring post-departure debriefs. Overall, 67% of PDs felt that their residents were moderately prepared for GH electives and 33% felt they were unprepared to some degree. Thirty-three percent believed that improvements should be made to either pre-departure training or both pre- and post-departure training, while 56% were unsure if improvements were needed. Forty-seven out of an estimated 380 residents responded. Thirty-five percent of residents had completed a GH elective during residency. Of residents who participated in a GH elective, only one (6%) reported feeling very prepared; 18 residents (43%) reported there was a need to improve trainings. Residents reported a number of challenges during electives (lack of resources, inadequate supervision, safety issues) and identified priority topics for training. Conclusion: Although EM residents are participating in GH electives, the majority of EM residency programs do not require pre- or post-departure training. Some PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure/post-elective GH training or to encourage EM residents to access university-wide training.

Introduction: Simulation is commonly used in medical education. It offers the opportunity for participants to apply theoretical knowledge and practice non-technical skills. We aimed to examine how simulation may also help to identify emergency medicine culture and serve as a tool to transmit values, beliefs and practices to medical learners. Methods: We undertook a focused ethnography of a simulated emergency department exercise delivered to 98 third-year medical students. This ethnography included participant-observation, informal interviews, and document review. Analysis was performed using a recursive method, a simultaneous deductive and inductive approach to data interpretation.We undertook a focused ethnography of a simulated emergency department exercise delivered to 98 third-year medical students. This ethnography included participant-observation, informal interviews, and document review. Analysis was performed using a recursive method, a simultaneous deductive and inductive approach to data interpretation. Results: All 20 staff (100%) and 92 of 98 medical students (94%) participated in the study. We identified 7 core values – identifying and treating dangerous pathology, managing uncertainty, patients and families at the center of care, balancing needs and resources at the system level, value of the team approach, education as integral, and emergency medicine as part of self-identity – and 27 related beliefs that characterized emergency medicine culture. We observed that culture was transmitted during the simulation exercise. Conclusion: This study contributes to the characterization of the culture of emergency medicine by identifying core values and beliefs that are foundational to the specialty. Simulation facilitated cultural compression which allowed for ready identification of values, beliefs and practices and also facilitated transmission of culture to learners. This study expands understanding of the culture of emergency medicine and the role of simulation in the process of cultural exchange.

Introduction: Simulation is used as a teaching technique in the medical curriculum, and especially for advanced life support (ALS). However, simulated ALS can differ greatly from real life ALS. The aim of this exploratory study was to identify the different disruptors associated with real life ALS. Methods: We conducted a cross-sectional, anonymous, online survey that included 32 items. It was distributed by email to emergency physicians from five emergency departments in Paris. The aim of this online survey was to identify the elements perceived as disruptors during ALS. Other aspects of the survey explored the perceived differences between simulated ALS and real life ALS. Descriptive statistics of percentage, mean and standard deviation were used to analyse the data. Results: Among 100 surveyed physicians, 43 (43%) answers were analysed. 53% were women with a mean age of 32 ± 3 years old. The identified disruptors from real life ALS were task interruptions mainly from non-medical staff (n = 16; 37%), patient's siblings (n = 5; 12%), other specialists (n = 5; 12%) and the phone calls (n = 2; 5%). The situation of ED overcrowding (n = 12; 28%) was also mentioned as a potential disruptor. Overall, physicians reported that some technical and non-technical tasks were harder to perform in real life compared to simulated sessions. Conclusion: This exploratory study allowed the identification of disruptors encountered in real life cases of ALS, and may be used for future simulation-based teaching to enhance realism during sessions

Introduction: Major trauma care is complex, and requires individuals and teams to perform together in time critical, high stakes situations. Scenario based simulation is well established as a strategy for trauma teamwork improvement, but its role in the relational and cultural aspects of trauma care is less well understood. Relational Coordination theory offers a framework though which we aimed to understand the impact of an established trauma simulation program Methods: We studied simulation activities using a narrative survey of trauma providers from anaesthesia, emergency medicine, medical imaging, surgery, trauma service, intensive care and pre-hospital providers at Gold Coast University Hospital, in conjunction with data from an ethnography. Data analysis was performed using a recursive approach - a simultaneous deductive approach using the relational coordination framework and an inductive analysis. Results: 95/480 (19.8%) staff completed free text survey questions on simulation. Deductive analysis of data from this narrative survey results using the RC framework domains identified examples of shared goals, shared knowledge, communication, and mutual respect. Two major themes from the inductive analysis – “Behaviour, process and system change”, and “Culture and relationships” - aligned closely with findings from the RC analysis, with additional themes of “Personal and team learning” and the “Impact of the simulation experience” identified. Conclusion: Our findings suggest that an established trauma simulation program can have a profound impact on the relational aspects of care and the development of a collaborative culture, with perceived tangible impacts on teamwork behaviours and institutional systems and processes. The RC framework – shared knowledge, shared goals and mutual respect in the context of communication that is timely, accurate, frequent and problem-solving based – can provide a common language for simulation educators to design and debrief simulation exercises that aim to have a translational impact.

Introduction: As physicians gain expertise in clinical settings, they are able to handle progressively more information, in both complexity and magnitude, as an organized schema. Expert physicians then, will be more likely to function with less cognitive load —the amount of mental effort someone exerts within their short-term working memory. Expert physicians will also retain more working memory capacity to process information during medical emergencies than novice physicians. While a physician's ability to process medical information may have implications for handling medical emergencies, there is a paucity of empirical research examining the link between physicians’ expertise and biometric measures of cognitive load. Using galvanic skin response (GSR) as a surrogate measure of cognitive load, we assess whether average cognitive load differs significantly between expert and novice physicians in a pulmonary embolism simulation exercise. Methods: We analyzed GSR data (n = 39) from a 10-minute simulated pulmonary embolism exercise among 18 faculty physicians and 21 residents. Cluster and factor analyses were used to identify novice, intermediate, advanced, and expert physicians with based on participants’ GRS scores. One-way ANOVA was used to analyze group differences. Descriptive statistical techniques were also used to describe the distribution of GRS expertise by participants’ level of training. Results: Contrary to expectation, we found more than two groups of resuscitation expertise in the simulation exercise. Respectively, we identified 7.7% and 20.5% of participants as novice and expert physicians. About 36% of participants were classified as intermediate (35.9%) physicians while another 36% were classified as having an advanced (35.9%) expertise in resuscitation. All the novice physicians identified were found to be PGY1 and PGY2 resident residents. A third (33.3%) of faculty physicians and 9.5% of residents were identified as experts. As expected, average GSR score for experts (x¯ = 0.60μS, SD = 0.26) was significantly (F = 137.6, p < 0.001) lower than the average GSR for novices (x¯ = 5.55μS, SD = 0.99), intermediate (x¯ = 2.84 μS, SD = 0.40), and advanced (x¯ = 1.57 μS, SD = 0.28) physicians. Conclusion: GSR measures of cognitive load may be used to identify resuscitation expertise in managing pulmonary embolism and related medical conditions through simulation exercises.