Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. The quality and clarity of audio transmission is paramount for effective and efficient communication. The aim of this study was to examine the impact of audio transmission quality on the results of paramedic patch calls. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests exclusively for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Pre-specified patch audio quality metrics, markers of transmission quality and comprehension as well as the resulting orders from the BHP were extracted. Differences between groups was compared using chi-square analyses. Results: 214 records were identified and screened initially. 91 ACRs and audio records were included in the analysis. At least one explicit reference to poor or inadequate call audio quality was made in 55/91 (60.4%) of calls and on average, 1.4 times per call. Of the 91 audited call records, 48 of 91 (52.7%) patches experienced an interruption of the call. Each time a call was interrupted, re-initiation of the call was required, introducing a mean [IQR] delay of 81 [33-68] seconds to re-establish verbal communication. Order requests made by paramedics in calls with no interruptions were approved in 30 of 43 patches (70%) while those requests made in calls with one or more interruptions were approved in only 21 of 48 cases (44%) (Δ26.0%; 95%CI 5.6-43.5%, p = 0.01). Conclusion: This retrospective review suggests that audio quality and interruptions of patch calls may impact a physician's ability to approve orders for interventions in the prehospital setting. Focus on infrastructure and technology underlying this important mode of communication may be a fruitful avenue for future improvements in systems where this may be an issue.

Introduction: Community paramedicine is well-established with an increasing evidence base to support its role in improving healthcare delivery in Canada and across the world. In British Columbia (BC), the BC Emergency Health Services (BCEHS) community paramedicine program provides an avenue to expand the Advanced Care Paramedic (ACP) role in underserved rural and remote communities across the province. Methods: We undertook stakeholder consultations using purposive sampling to better understand the barriers and facilitators impacting the integration of rural advanced care community paramedics (RACCPs) in 6 BC communities and to evaluate stakeholder perspectives of the implementation and impacts of the RACCP. 18 in-depth interviews were completed with a diverse range of stakeholders. The interviews were analyzed using a qualitative descriptive approach and the Theoretical Domains Framework. Results: A number of key facilitators and barriers to implementation of the RACCP were identified. Facilitators included the RACCP bridging significant gaps in existing community-based healthcare services including palliative care, harm reduction, and home-based assessment. The RACCP also provides leadership within their communities by actively engaging in the delivery of informal and formal debriefing, mentorship, and education. Identified barriers to RACCP implementation included confusion over the scope of the RACCP role, lack of shared health data, and various regulatory challenges. Several priority areas for ongoing development were also identified including workforce planning, addressing regulatory requirements, developing a strategic and systematic activation and dispatch process, providing continuing mentorship and supports for RACCPs, and the importance for ongoing engagement with end-users to determine the impact of the RACCP role for community health services. Conclusion: This research provides a strong foundation for addressing healthcare delivery in rural and remote BC by identifying the unique challenges communities face in healthcare provision and is a leading initiative for the ongoing development of professional paramedic practice across the province.

Introduction: The #MeToo social media movement gained international status in October 2017 as millions disclosed experiences of sexual and intimate partner violence. People who experience violence from a former/current intimate partner may not present for care for many reasons, among them not knowing where to go for care, or not realizing they were experiencing abuse since the behavior was portrayed as ‘normal’. Empirical research identified increased police reporting, internet searches, and new workplace regulations on sexual assault/harassment after #MeToo. Less is known about how #MeToo has influenced hospital-based care, particularly among IPV cases. We aimed to investigate if the #MeToo social movement influenced patterns of IPV cases presenting for emergency care. Methods: This study took place at the Sexual Assault and Partner Abuse Care Program (SAPACP), within the Emergency Department of The Ottawa Hospital. Patients seen from November 1st, 2016 through to September 30th, 2017 was considered Pre-#MeToo and those seen November 1st, 2017 to September 30th, 2018 was considered Post-#MeToo. All patients seen in October 2017 were excluded. Analyses compare the proportion and characteristics of IPV cases seen Pre- and Post-#MeToo. Log-binomial regression models were used to calculate relative risk and 95% CI. Results: 890 cases were seen by the SAPACP during the total study period, of which 564 (63%) were IPV cases. 258 IPV cases were seen Pre-#MeToo and 306 IPV Post-#MeToo. The clinical presentation for IPV cases was similar between both periods where approximately 42% of IPV cases presented for sexual assault, 50% presented for physical assault. An increase in frequency and proportion of IPV cases was observed post-#MeToo. Post-#MeToo there were 48 additional cases of IPV, corresponding to almost a 20% increase in risk compared to the Pre-#MeToo period. (RR: 1.19, 95% CI: 1.07-1.31) Post-#MeToo, there were more presenting cases of IPV among male/trans cases (9 vs 26) and youth cases (82 vs 116). Conclusion: #MeToo is a powerful social movement that corresponded with a significant increase in IPV cases presenting for emergency care. While the assault characteristics among IPV cases remained similar, an important contribution of this research is the increase in youth, male/transgender patients who presented for care post-#MeToo. Continued investigations into pre- post-#MeToo trends is needed to understand more about the changing clinical population and to inform resource and service allocation.

Introduction: The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial haemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. Methods: This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. Results: From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). Conclusion: In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.

Introduction: Trauma care is highly complex and prone to medical errors. Accordingly, several studies have identified adverse events and conditions leading to potentially preventable or preventable deaths. Depending on the availability of specialized trauma care and the trauma system organization, between 10 and 30% of trauma-related deaths worldwide could be preventable if optimal care was promptly delivered. This narrative review aims to identify the main determinants and areas for improvements associated with potentially preventable trauma mortality. Methods: A literature review was performed using Medline, Embase and Cochrane Central Register of Controlled Trials from 1990 to a maximum of 6 months before submission for publication. Experimental or observational studies that have assessed determinants and areas for improvements that are associated with trauma death preventability were considered for inclusion. Two researchers independently selected eligible studies and extracted the relevant data. The main areas for improvements were classified using the Joint Commission on Accreditation of Healthcare Organizations patient event taxonomy. No statistical analyses were performed given the data heterogeneity. Results: From the 3647 individual titles obtained by the search strategy, a total of 37 studies were included. Each study included between 72 and 35311 trauma patients who had sustained mostly blunt trauma, frequently following a fall or a motor vehicle accident. Preventability assessment was performed for 17 to 2081 patients using either a single expert assessment (n = 2, 5,4%) or an expert panel review (n = 35, 94.6%). The definition of preventability and the taxonomy used varied greatly between the studies. The rate of potentially preventable or preventable death ranged from 2.4% to 76.5%. The most frequently reported areas for improvement were treatment delay, diagnosis accuracy to avoid missed or incorrect diagnosis and adverse events associated with the initial procedures performed. The risk of bias of the included studies was high for 32 studies because of the retrospective design and the panel review preventability assessment. Conclusion: Deaths occurring after a trauma remain often preventable. Included studies have used unstandardized definitions of a preventable death and various methodologies to perform the preventability assessment. The proportion of preventable or potentially preventable death reported in each study ranged from 2.4% to 76.5%. Delayed treatment, missed or incorrect initial diagnosis and adverse events following a procedure were commonly associated with preventable trauma deaths and could be targeted to develop quality improvement and monitoring projects.

Introduction: Choosing Wisely Canada has reported rates of unnecessary head computed tomography (CT) scans for low-risk mild traumatic brain injury (mTBI) patients in Ontario and Alberta ranging from 14% to 46%. Local data for Quebec is currently not available. We sought to estimate the overuse of CT scans among adults with mTBI in the emergency department (ED) of a single level II trauma center in Quebec. Methods: We performed a retrospective chart review of adults who visited the ED of Hôtel-Dieu de Lévis from 04/01/2016 to 03/31/2017. Using an administrative database (Med-GPS, Montreal), we randomly sampled ED patients aged over 18 that had an initial Glasgow Coma Scale score of 13 to 15 and had suffered from a mTBI in the last 24 hours. We excluded patients with an unclear history of trauma, a bleeding disorder/anticoagulation, a history of seizure, any acute focal neurological deficit, a return visit for reassessment of the same injury, unstable vital signs, or a pregnancy. Data was extracted by two reviewers who analyzed separate charts. They used the Canadian CT Head Rule (CCHR) to determine relevance of CT scans. Overuse was determined if a patient without any high or medium risk CCHR criteria underwent a scan. A third reviewer verified a 10% random sample of the data extraction for each primary reviewer and inter-rater reliability was assessed using the kappa statistic. Results: From the 942 eligible mTBI patients, we randomly selected 418 patient charts to review, of which 217 met all inclusion and exclusion criteria (56% were men and the mean age was 48 years old (SD = 21)). Among included patients, 101 were determined as low risk. The overuse proportion was 26% (26/101), 95% CI [18-35]. Two CT scans were assessed as abnormal, but none revealed life-threatening injuries and only one was considered clinically significant with a subdural hematoma of 9 mm. Inter-rater reliability was substantial to perfect (kappa = 0.6 and 1.0) for each primary reviewer. Conclusion: We identified head CT scan overuse in this ED. This will support local quality improvement initiatives to reduce unnecessary head CT scans for adults with mTBI.

Introduction: Minor thoracic trauma (MTI) accounts for approximately 15% of all injuries treated in the emergency department (ED). Many of which are minor and will be handle on an outpatient basis. MTI and rib fractures especially cause non-negligible pain. The pain experienced by patients can lead to reduce pulmonary function, decrease mucous clearance and decrease cough capacity leading in infectious problems and atelectasis. To our knowledge, there is no study of atelectasis development caused by reduced cough capacity in the setting of MTI. Objective: Evaluate if a variation in cough capacity leads to atelectasis development. Evaluate if there was a difference in cough capacity perception between the nurse, the physician and the patient himself. Methods: A prospective observational cohort study (2006-2012) in 4 ED recruited patients with a chief complaint of MTI, ≥ 16 years old, discharged home from the ED. Exclusion criteria: 1) a confirmed hemothorax, pneumothorax, fail chest, lung contusion or any other important thoracic or abdominal internal injury at the initial visit or unable to attend follow-up visits. Patients were assessed at 7- and 14- days. For each patient, age, sex, mechanism of injury, dyspnea, COPD/asthma and smoking status were collected. Chest x-ray was done at each visit; pulmonary complications were assessed by a blind radiologist. Cough capacity was assessed on a scale of 0 to 10 by a nurse, physician and patient himself at 0, 7- and 14- days. Pain was scored on a scale of 0 to 10. Chi -squared and odds ratio (IC: 95%. p ≤ 0.05) were assessed to determine if the cough capacity variation leads to atelectasis development. A Pearson correlation test was assessed the correlation in cough capacity among participants. Results: 1474 patients were recruited. Initial visit: 9% had atelectasis, 7 days: 7% and 4.6% at 14 days. 1105 patients were retained for analysis after exclusion of missing data. The median initial pain score was 7-8 for all patient categories. At 7 days, the odds ratio of atelectasis development were (score (0-3) 1.18 (0.42-3.34); score (4-7) 1.20 (0.48-3.03); p<=0.05). The Pearson correlation of cough capacity assessment, in patients without atelectasis were (0.53 nurse vs. patient; 0.37 physician vs. patient; 0.51 nurse vs. physician p<=0.05). As for the cough capacity perception correlation in patients with atelectasis were (0.62 nurse vs. patient; 0.40 physician vs. patient; 0.51 nurse vs. physician; p<=0.05). Conclusion: There is no statistically significant difference in atelectasis development depending on cough capacity and there is poor correlation regarding the perception of cough capacity except for the nurse. It would be interesting to develop a patient reported outcome measure questionnaire which targets minor thoracic trauma as it is a common emergency department complaint and it could help us improve medical management and patient quality of life

Introduction: Inhaled toxins from tobacco smoking, cannabis leaf smoking as well as vaping/e-cigarette products use are known causes of cardio-respiratory injury. While tobacco smoking has decreased among Canadian adults, there are now several other forms of legal inhalant products. While legal, the evidence of benefit and safety of vaping is limited. Of concern, cases of e-cigarette or vaping products use associated lung injury (EVALI) have been accumulating in the U.S. and now in Canada. Despite this, very little is known about the inhalation exposure of emergency department (ED) patients; this study was designed to explore lung health in the ED. Methods: We investigated the prevalence of exposure to vaping, tobacco and cannabis among patients presenting to a Canadian ED from July to November 2019. Ambulatory (CTAS 2 to 5), stable, adult (≥ 17 years) patients were prospectively identified and invited to complete a survey addressing factors related to lung health (previous diagnosis of respiratory conditions and respiratory symptoms at the ED presentation) and information on current exposure to vaping, tobacco and cannabis smoking. Categorical variables are reported as frequencies and percentages; continuous variables are reported as medians with interquartile range (IQR). The study was approved by the Health Research Ethics Board. Results: Overall, 1024 (71%) of 1433 eligible patients completed the survey. The median age was 43.5 (IQR: 29, 60), and 51% were female. A total of 351 (31%) participants reported having been previously diagnosed with ≥1 respiratory conditions, and 177 (17%) were visiting the ED as a result of ≥1 respiratory symptoms (e.g., cough, shortness of breath, wheezing). Daily tobacco smoking was reported by 190 (19%), and 83 (8%) reported using vaping/e-cigarette products. Cannabis use within 30 days was described by 80 (15%) respondents. Exposure to tobacco and vaping products was reported by 39 (4%) participants, 63 (6%) reported using tobacco in combination with cannabis smoking, and 3% reported combining vaping and cannabis use. Conclusion: Patients seeking care in the ED are exposed to a large quantity of inhaled toxins. Vaping products, considered the cause of the most recent epidemic of severe lung injury, are used in isolation and in combination with other smoking products in Canada. These exposures should be documented and may increase the risk of lung health injuries and exacerbations of chronic respiratory conditions.

Introduction: The Emergency Medicine Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) has specified that resuscitation Entrustable Professional Activities (EPAs) can be assessed in either the workplace or simulation environments; however, there is minimal evidence that such clinical performance correlates. We sought to determine the relationship between assessments in the workplace versus simulation environments among junior emergency medicine residents. Methods: We conducted a prospective observational study to compare workplace and simulation resuscitation performance among all first-year residents (n = 9) enrolled in the RCPSC-Emergency Medicine program at the University of Ottawa. All scores from Foundations EPA #1 (F1) were collected during the 2018-2019 academic year; this EPA focuses on initiating and assisting in the resuscitation of critically ill patients. Workplace performance was assessed by clinical supervisors by direct observation during clinical shifts. Simulation performance was assessed by trained simulation educators during regularly-scheduled sessions. We present descriptive statistics and within-subjects analyses of variance. Results: We collected a total of 104 workplace and 36 simulation assessments. Interobserver reliability of simulation assessments was high (ICC = 0.863). We observed no correlation between mean EPA scores assigned in the workplace and simulation environments (Spearman's rho=−0.092, p = 0.813). Scores in both environments improved significantly over time (F(1,8) = 18.79, p < 0.001, ηp2 = 0.70), from 2.9(SD = 1.2) in months 1-4 to 3.5(0.2) in months 9-12 (p = 0.002). Workplace scores (3.4(0.1)) were consistently higher than simulation scores (2.9(0.2)) (F(1,8) = 7.16, p = 0.028, ηp2 = 0.47). Conclusion: We observed no correlation between EPA F1 ratings of resuscitation performance between the workplace and simulation environments. Further studies should seek to clarify this relationship to inform our ongoing use of simulation to assess clinical competence.

Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age >=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p < 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were <2% and adverse events were <5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.

Introduction: Determining fluid status prior to resuscitation provides a more accurate guide for appropriate fluid administration in the setting of undifferentiated hypotension. Emergency Department (ED) point of care ultrasound (PoCUS) has been proposed as a potential non-invasive, rapid, repeatable investigation to ascertain inferior vena cava (IVC) characteristics. Our goal was to determine the feasibility of using PoCUS to measure IVC size and collapsibility. Methods: This was a planned secondary analysis of data from a prospective multicentre international study investigating PoCUS in ED patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility using a standard data collection form in 6 centres. The primary outcome was the proportion of patients with a clinically useful (determinate) scan defined as a clearly visible intrahepatic IVC, measurable for size and collapse. Descriptive statistics are provided. Results: A total of 138 scans were attempted on 138 patients; 45.7% were women and the median age was 58 years old. Overall, one hundred twenty-nine scans (93.5%; 95% CI 87.9 to 96.7%) were determinate. 131 (94.9%; 89.7 to 97.7%) were determinate for IVC size, and 131 (94.9%; 89.7 to 97.7%) were determinate for collapsibility. Conclusion: In this analysis of 138 ED patients with undifferentiated hypotension, the vast majority of PoCUS scans to investigate IVC characteristics were determinate. Future work should include analysis of the value of IVC size and collapsibility in determining fluid status in this group.

Introduction: Cardiotoxicants poisonings are rare but have the potential to be highly lethal. Given the precarious nature of these poisonings, the Quebec Poison Control Center (CAPQ) has established a management protocol for optimal treatment. This study seeks to evaluate whether CAPQ's Calcium Channel Blocker (CCB) poisoning management protocol improves treatment delivery by physicians using simulation. The primary outcome is whether the management protocol decreases time to delivery of calcium and insulin. The secondary outcome is whether use of the management protocol increases appropriate dosing. Methods: For this randomized AB / BA crossover trial, Emergency Medicine and Internal Medicine residents were randomly assigned to one of two groups; one group received the management protocol during the simulation and the other did not. The crossover occurred 3-months later whereby the groups were reversed. Inverse probability weighting was used to compensate for losses at follow-up. Differences in baseline characteristics, as well as carry-over effect, were evaluated. The outcomes were analyzed with a two-level hierarchical model. Results: Twenty-three residents were included in the study. No significant differences in baseline characteristics were noted between the AB / BA groups, and no carry-over effect was identified on statistical analysis for all variables. As for the primary outcomes, time to administration of IV calcium decreased by 87 seconds (CI -266 to 92), time to insulin bolus decreased by 52 seconds (-217 to 114), and time to insulin infusion decreased by 115 seconds (-213 to -18) when the protocol was used. As for the secondary outcomes, there were no statistically significant differences for the percentage of adequate doses of IV calcium (RR: 1.27; 95% CI: 0.80–2.02), insulin bolus (RR: 1.30; 95% CI: 0.80–2.12) and insulin infusion (RR: 1.37; 95% CI: 0.99–1.91). Conclusion: This randomized cross-over study, which uses simulation to evaluate the performance of CAPQ's CCB poisoning management protocol, does not statistically demonstrate decreased time to administration or increased accuracy of dosing, due to the large confidence intervals. Unfortunately, we were not able to obtain the planned sample size due to limited participation. However, our results trend towards more optimal dosing and rapid dosing of treatments, and from a qualitative standpoint, the protocol appeared to increase the structure of patient care.

Introduction: The incidence of out-of-hospital cardiac arrest (OHCA) in school is approximately 2.1 for 100,000 per year. Although rare, it is a devastating event for the local community. Schools with public access to automated external defibrillators (AED) and an emergency response plan have demonstrated increased survival rates of up to 70% for students who suffer cardiac arrest. Previous studies identified numerous barriers to successful cardiac resuscitation in public school systems. The main objectives of this study were to identify those barriers in the Quebec region elementary school system and to assess the impacts of an AED focused training session. Methods: A previously validated survey focused on the potential barriers to successful defibrillation in OHCA and on demographic variables was sent to 139 elementary schools. Later, 92 employees within three elementary schools who responded to the survey were evaluated before and after receiving training on the use of AED in a mock cardiac arrest scenario. The primary outcome was the time to first shock and the secondary outcomes included correct AED pad placement and safety of the procedure. Results: Survey response rate was 53%, which is comparable to previous studies assaying barriers to cardiac resuscitation in public school systems. 95% of school respondents reported the presence of an AED on the school premises but 46% stated that no formal AED training course was provided to employees. Out of the four schools who reported a previous OHCA, only one had access to an AED at the time of the event. Following focused AED training, 92% of school workers successfully completed a defibrillation sequence in a mock scenario, from 53% before (p < 0.001, McNemar test). The time to first shock went from 66 seconds (95% CI 63-70) to 47 seconds (95% CI 45-49; -29%, p < 0.001). Proper pad placement was the most problematic step for participants and personnel who reported previous training had better performance (OR 3.15, 95% CI 1.33-7.42, p = 0.009). Conclusion: Most elementary schools in the Quebec region have access to AEDs. However, inadequate AED training represents a significant barrier to successful defibrillation in the event of an OHCA. Our results showed that a simple focused AED training could improve the performance of school workers and optimize the chain of survival.

Introduction: Intraosseous (IO) and intravenous (IV) access to the vascular system for the delivery of fluid and medication is a component of advanced pediatric resuscitation. Data describing the use of IV or IO vascular access methods and outcomes of pediatric out-of-hospital cardiac arrest (OHCA) are limited. Methods: We analyzed prospectively collected data of non-traumatic OHCA of the Resuscitation Outcomes Consortium registry in Canada and the USA (2011-2015). We included patients 17 years of age and younger who were treated by emergency medical services (EMS). We described the vascular access routes utilized, and the success rate of these attempts. We performed a logistic regression model, to evaluate the association of vascular access route and survival, adjusting for age, sex, shockable initial rhythm, witnessed status, public location, EMS arrival interval and time from 911 call to vascular access. In this model, we excluded patients with failed, multiple site or no vascular access attempts during the resuscitation. Results: Of 1549 non-traumatic pediatric OHCA, 822/895 (92%) and 345/488 (71%) had successful IO and IV vascular access attempts, respectively. IO access was more common in younger cases. Of 761 cases included in the regression model, 30/601 (5%) of IO-treated cases survived to hospital discharge, in comparison to 40/160 (25%) of IV-treated cases. Intraosseous access was associated with a decreased survival to hospital discharge (adjusted OR 0.46; 95% CI 0.21 to 0.98). Conclusion: In pediatric patients with OHCA, intraosseous vascular access was more commonly successful than IV placement and more common among younger cases. However, in cases with successful vascular access, IO use was associated with lower survival to hospital discharge.

Introduction: The elderly (65 yo and more) increase in Canada is well documented along with a disproportionate use of Emergency Departments after a minor injury. These patients requires specific care given a 16% risk of functional decline following a visit to ED. To prevent functional decline, a multidimensional assessment of the elderly is recommended in the emergency department. Objective: To determine if ED grip strength can predict functional decline at 3 or 6 months post-injury. Methods: A multicentre prospective study in 5 ED across Canada was realized between 2013 and 16. Patients 65 years old and over, autonomous in daily living activities and consulting the emergency department for minor trauma were recruited 7 days a week. Clinical-demographic data, functional status, fear of falling, number of falls in the last month, grip strength measurement were collected in the ED. Functional decline (loss of at least points to functional status) was calculated at 3 and 6 months. Descriptive statistics and linear regression model with repeated measurements were used to determine if the grip strength was predictive of functional decline at 3 or 6 months. Results: 387 patient were recruited. Mean age was 74 ± 7 years old, 52% were male. XXX experienced a fall in the last month. The initial maximum grip strength was (24 ± 10 intervention vs. 28 ± 13 control; p ≤ 0.05). grip strength is associated with pre-injury functional status (p < 0.0001) and fear of falling (p = 0.0001) but does not predict 3 or 6 month functional decline. Conclusion: Given the strong association with fear of falling and functional status at initial ED evaluation, we recommend that grip strength measurement could be included in a multidisciplinary geriatric emergency department assessment as needed.

Introduction: It is believed by some that emergency physicians prescribe more opioids than required to manage patients’ pain, and this may contribute to opioid misuse. The objective of our study was to assess if there has been a change in opioid prescribing practices by emergency physicians over time for undifferentiated abdominal pain. Methods: A medical record review for adult patients presenting at two urban academic tertiary care emergency departments was conducted for two distinct time periods; the years of 2012 and 2017. The first 500 patients within each time period with a discharge diagnosis of “abdominal pain” or “abdominal pain not yet diagnosed” were included. Data were collected regarding analgesia received in the emergency department and opioid prescriptions written. Opioids were standardized into morphine equivalent doses to compare quantities of opioids prescribed. Analyses included t-test for continuous and chi-square for categorical data. Results: 1,000 patients were included in our study. The mean age was 42.0 years and 69.6% of patients were female. Comparing 2017 to 2012, there was a non-significant decrease in opioid prescriptions written for patients discharged directly by emergency physicians, from 17.8% to 14.4% (p = 0.14). Mean opioid quantities per prescription decreased from 130.4 milligrams of morphine equivalents per prescription to 98.9 milligrams per prescription (p = 0.002). 13.9% of opioid prescriptions in 2017 were for more than 3 days, which is a decrease from 28.1% in 2012. During the emergency department care, there was an increase in foundational analgesia use prior to initiating opioids from 17.6% to 26.8% (p = 0.001). There was also a decrease for within ED opioid analgesia use from 40.0% to 32.8% (p = 0.018). Conclusion: Opioid prescription rates did not change significantly during our study. However, physicians reduced the quantity of opioids per prescription and used less opioid analgesia in the emergency department for abdominal pain of undetermined etiology.

Introduction: Adult Emergency Departments (EDs) in Calgary are facing a crisis of boarded patients admitted to psychiatric in-patient units. In psychiatric emergency care, “boarding” describes the holding of patients in the ED after the decision to admit has been made by a staff psychiatrist and a bed request has been submitted. Literature review suggests psychiatric patients face exorbitantly higher boarding times than any other service in the hospital however little is published on the nature of these adverse events. Examples of adverse patient events from a psychiatric perspective could include: the need to initiate mechanical and/or chemical restraints after admission and while still in the ED, attempts to self-harm, and verbal and physical assault on ED staff. Methods: This study quantifies the incidence of adverse events experienced by psychiatric patients while boarded in the ED. It uses a retrospective chart review of all adult psychiatric patients, age 18 - 55yo, who presented to one of four adult EDs and who were admitted to a psychiatric in-patient unit in the Calgary Zone between January 1, 2019 and May 15, 2019. A randomly generated convenience sample identified 200 patients, 50 from each site, for in-depth review. Results: During the study time period, 1862 adult patients were admitted from emergency departments to the psychiatry service across all four sites. Of the 200 charts reviewed, patients ranged in age from 26-41 (average 34). 52.5% were male with the majority being admitted to a non-high observation bed. The average boarding time was 23.5 hours with an average total ED length of stay of 31 hours for all comers. Those who experienced an adverse event while boarded in the ED experienced a significantly prolonged average boarding time (35 hours) compared to those who did not experience an adverse event (6.5 hours) (p = 0.005). Significant adverse events were associated with the specific hospital site and the type of admission bed needed (high observation versus normal versus short stay) (p < 0.05). Conclusion: Psychiatric patients boarded in Calgary EDs experience a number of significant adverse events. The importance of understanding the reality of the conditions that psychiatric ED patients face while waiting for in-patient placement cannot be overstated. This study is important to emergency medicine as it will allow for deeper understanding of the patient experience while in the ED and identifies areas that may require further advocacy amongst ED staff and our psychiatry colleagues.

Introduction: People experiencing homelessness have complex psychiatric and medical presentations, and have poor access to primary care. Thus, emergency departments (EDs) often become their main point of healthcare contact. Using routinely collected administrative data from EDs, we examine the ED utilization, health and reasons for presentations of people experiencing homelessness.. Methods: All routinely collected administrative health data from EDs located within Ontario, Canada from 2010-2017 were analyzed. Individuals experiencing homelessness were identified by a marker that was adopted in 2009 replacing their recorded postal code with an XX designation. Outcomes include number of unique patients, number of visits and repeat visits, CTAS scores, ambulance utilization, and type of ICD-10 presentation. Results: 640,897 visits to the ED over 10 years were made by 39,525 unique individuals experiencing homelessness. A visit to an ED by a homeless patient resulted in repeat presentation on the same day 5% of the time. The median repeat presentation to an ED was 14 days. In people experiencing homelessness, the most prevalent category of presentations were primary mental health diagnoses, accounting for 34.8% of visits (n = 223,392). Under mental health conditions, psychoactive substance use presentations made up more than 54% of the presentations (n = 121,112). Alcohol was by far the most common cause of substance use/induced disorders (n = 84,805). Conclusion: Applications of administrative data presents a novel method of measuring health and healthcare outcomes for marginalized populations. We found people experiencing homelessness are presenting to ED more frequently in Ontario, with significant mental health and addiction problems. Our study identifies several important health vulnerabilities within the population, which may serve as potential targets for future interventions.

Introduction: Many cardiac arrest survivors die later due to hemorrhage or thromboembolism, thought to be caused by acquired coagulopathy in post-cardiac arrest syndrome (PCAS) from shock and reperfusion injury. Understanding PCAS is a priority identified by the AHA for the prevention of complications in cardiac arrest survivors. Shock dysregulates both coagulation and fibrinolysis. The key effector enzyme thrombin (Th), is responsible for both up- and down-regulating coagulation and fibrinolysis. Measuring early Th activity may allow for predicting PCAS coagulopathy, and early medical intervention in the ED. Therefore, we aimed to characterize the time-course profile of early coagulation using an established pig model of cardiac arrest. Methods: Yorkshire pigs were anaesthetised and intubated, had VF-arrest induced by pacing, and were resuscitated per ACLS. Rotational thromboelastometry (ROTEM) was performed on whole blood at four times: baseline, intra-arrest, post-arrest, and death, using the fibrin-based test with tissue factor to initiate clotting in the presence of a platelet inhibitor cytochalasin D (FIBTEM). Clot time (CT), clot formation time (CFT), alpha-angle during clot formation (Alpha), clot amplitude at 10 min (A10), maximum clot firmness (MCF), and maximum lysis as total percentage (ML%) were quantified. The primary outcome is the overall coagulation initiation measured by CFT, while secondary outcomes include ROTEM parameters reflecting Th activity. Parameters are compared over time in SPSS using repeated measures ANOVA and Bonferroni correction. Results: Pilot data from one experiment show that cardiac arrest causes immediate early changes to coagulation that subsequently normalized with ROSC (Figure 1). CFT was impaired immediately upon cardiac arrest (2.3-fold increase), normalized with ROSC, and impaired again at death when compared with baseline. Consistent with clotting impairment, A10, Alpha, and MCF were all reduced with cardiac arrest, normalized with ROSC, and impaired again at death. Conclusion: Higher initial indices of coagulopathy in patients with cardiac arrest appear to correlate with death and thromboembolism. In this pilot, CFT is acutely modified by cardiac arrest. Since CFT is affected by overall Th activity, early Th dysregulation may be a critical driver of coagulopathy. Th may therefore be a lead target that is modifiable in the emergency post-arrest setting to decrease morbidity and mortality from PCAS in cardiac arrest survivors.

Introduction: Point-of-care ultrasound (POCUS) has become standard practice in emergency departments ranging from remote rural hospitals to well-resourced academic centres. To facilitate quality assurance, the Canadian Association of Emergency Physicians (CAEP) recommends image archiving. Due in part to poor infrastructure and lack of a national standard, however, archiving remains uncommon. Our objective was to establish a minimum standard archiving protocol for the core emergency department POCUS indications. Methods: Itemization of potential archiving standards was created through an extensive literature review. An online, three-round, modified Delphi survey was conducted with the thirteen POCUS experts on the national CAEP Emergency Ultrasound Committee tasked with representing diverse practice locations and experiences. Participants were surveyed to determine the images or clips, measurements, mode, and number of views that should comprise the minimum standard for archiving. Consensus was pre-defined as 80%. Results: All thirteen experts participated fully in the three rounds. In establishing minimum image archiving standards for emergency department POCUS, complete consensus was achieved for first trimester pregnancy, hydronephrosis, cardiac activity versus standstill, lower extremity deep venous thrombosis, and ultrasound-guided central line placement. Consensus was achieved for the majority of statements regarding abdominal aortic aneurysm, extended focused assessment with sonography in trauma, pericardial effusion, left and right ventricular function, thoracic B-line assessment, cholelithiasis and cholecystitis scans. In total, consensus was reached for 58 of 69 statements (84.1%). This included agreement on 41 of 43 statements (95.3%) describing mandatory images for archiving in the above indications. Conclusion: Our modified Delphi-derived consensus represents the first national standard archiving requirements for emergency department POCUS. Depending on the clinical context, additional images may be required beyond this minimum standard to support a diagnosis.