Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P < 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P < 0.01), electrical cardioversion (45.1% vs 56.8%; P < 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P < 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P < 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.

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: Geriatric patients commonly present to the emergency department (ED) after a fall. Unfortunately, recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric falls guidelines. This study applied a theoretical domains framework (TDF)-driven approach to systematically investigate barriers and enablers in the provision of guideline-based care to older patients presenting to the ED with a fall. Methods: From June to September 2017, semi-structured interviews of staff ED physicians practicing in Ontario, Canada were conducted and analyzed. An interview guide based on the TDF was used to capture 14 domains that may influence provision of guideline-based care. Interview transcripts were analyzed, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs, and evidence of strong beliefs that would influence provision of guideline-based care. Results: Eleven interviews were conducted with practicing ED physicians. Thirty specific belief statements across 13 different TDF domains (all except Optimism) were identified as relevant. Overall, Ontario ED physicians are supportive of providing guideline-based care and believe it would lead to better outcomes for geriatric falls patients. Important barriers include knowledge, skills, time and workload constraints, and inconsistent allied health support. Conclusion: This study identified important barriers and enablers to provision of guideline-based care in geriatric ED falls patients. These results will help guide implementation of guidelines nationally and internationally, with a focus on improved knowledge dissemination, implementation of training interventions, and improvements in allied health coverage and supports.

Introduction: We wished to identify emergency department interventions that lead to improvement in door-to-ECG times for adults presenting with symptoms suggestive of acute coronary syndrome (ACS). Methods: Two reviewers searched Medline, Embase, CINAHL and Cochrane CENTRAL from inception to April 2018 for studies in adult emergency departments with an identifiable intervention to reduce median door-to-ECG times when compared to the institution's baseline. Quality was assessed using the ‘Quality Improvement Minimum Quality Criteria Set’ (QI-MQCS) critical appraisal tool. The primary outcome was the absolute median reduction in door-to-ECG times as calculated by the difference between the post-intervention time and pre-intervention time. Results: Two reviewers identified 809 unique articles, yielding 11 before-after quality improvement studies that met eligibility criteria (N = 15,622 patients). The majority of studies (10/11) reported bundled interventions and most (10/11) showed statistical improvement in door-to-ECG times. The most common interventions were: having a dedicated ECG machine and technician in triage (5/11); improved triage education (4/11); improved triage disposition (2/11); and data feedback mechanisms (1/11). Conclusion: There are multiple interventions that show promise for reducing emergency department door-to-ECG times. Effective bundled interventions include having a dedicated ECG technician, triage education and better triage disposition. These changes, bundled together, can help intuitions attain best practice guidelines. Emergency departments must first understand their local context before adopting any single or group of interventions.

Background: External ventricular drain (EVD) insertion is a common neurosurgical procedure performed in patients with life-threatening conditions, but can be associated with complications. The objectives of this study are to evaluate data on national practice patterns and complications rates in order to optimize clinical care Methods: The Canadian Neurosurgery Research Collaborative conducted a prospective multi-centre registry of patients undergoing EVD insertions at Canadian residency programs Results: In this interim analysis, 4 sites had recruited 46 patients (mean age: 53.9 years, male:female 2:1). Most EVD insertions occurred outside of the operating theatre, using free-hand technique, and performed by junior neurosurgery residents (R1-R3). The catheter tip was in the ipsilateral frontal horn or body of the lateral ventricle in 76% of cases. Suboptimally placed catheters did not have higher rates of short-term occlusion. EVD-related hemorrhage occurred in 6.5% (3/45) with only 1 symptomatic patient. EVD-related infection occurred in 13% (6/46) at a mean of 6 days and was associated with longer duration of CSF drainage (P=0.039; OR: 1.13) Conclusions: Interim results indicate rates of EVD-related complications may be higher than previously thought. This study will continue to recruit patients to confirm these findings and determine specific risk factors associated with them

Introduction: Current guideline recommendations for optimal management of non-purulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is currently a lack of evidence to guide emergency physicians on when to select oral versus intravenous antibiotic therapy. The primary objective was to identify risk factors associated with oral antibiotic treatment failure. A secondary objective was to describe the epidemiology of adult emergency department (ED) patients with non-purulent SSTIs. Methods: We performed a health records review of adults (age 18 years) with non-purulent SSTIs treated at two tertiary care EDs. Patients were excluded if they had a purulent infection or infected ulcers without surrounding cellulitis. Treatment failure was defined any of the following after a minimum of 48 hours of oral therapy: (i) hospitalization for SSTI; (ii) change in class of oral antibiotic owing to infection progression; or (iii) change to intravenous therapy owing to infection progression. Multivariable logistic regression was used to identify predictors independently associated with the primary outcome of oral antibiotic treatment failure after a minimum of 48 hours of oral therapy. Results: We enrolled 500 patients (mean age 64 years, 279 male (55.8%) and 126 (25.2%) with diabetes) and the hospital admission rate was 29.6%. The majority of patients (70.8%) received at least one intravenous antibiotic dose in the ED. Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR]=6.31, 95% CI=1.80 to 22.08), chronic ulcers (OR=4.90, 95% CI=1.68 to 14.27), history of MRSA colonization or infection (OR=4.83, 95% CI=1.51 to 15.44), and cellulitis in the past 12 months (OR=2.23, 95% CI=1.01 to 4.96) were independently associated with oral antibiotic treatment failure. Conclusion: This is the first study to evaluate potential predictors of oral antibiotic treatment failure for non-purulent SSTIs in the ED. We observed a high rate of treatment failure and hospitalization. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for non-purulent SSTIs being managed as outpatients.

Introduction: Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). To date, there are no prospective studies describing the performance of an ED-to-OPAT clinic program. Furthermore, there are no studies that have examined physician rationale for intravenous therapy, despite this being a critical first step in the decision to refer to an OPAT program. Methods: We conducted a prospective observational cohort study of adults (age 18 years) with non-purulent SSTIs receiving parenteral therapy at two tertiary care EDs. Patients were excluded if they had purulent infections or could not provide consent. The emergency physician completed a form documenting rationale for intravenous therapy, infection size, and choice of antimicrobial agent, dose and duration. OPAT treatment failure was defined as hospitalization after a minimum of 48 hours of OPAT for: (i) worsening infection; (ii) peripheral intravenous line complications; or (iii) adverse antibiotic events. Patient satisfaction was assessed at a 14-day telephone follow up. Results: We enrolled a consecutive sample of 153 patients (mean age 60 years, 82 male (53.6%) and 38 (24.8%) with diabetes). A total of 137 patients (89.5%) attended their clinic appointment. Of the 101 patients prescribed cefazolin, 50.5% received 1000 mg and 48.5% received 2000 mg per day. There were low rates of OPAT treatment failure (3.9%). None of the adverse peripheral intravenous line events (9.8%) or adverse antibiotic events (7.2%) required hospitalization. Patients reported a high degree of satisfaction with timeliness of clinic referral (median score 9 out of 10) and overall care received (median score of 10 out of 10). The top 5 reasons given by physicians for selecting intravenous therapy were: clinical impression of severity (52.9%); failed oral antibiotic therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). Conclusion: This is the first study to identify physician rationale for the use of intravenous antibiotics for SSTIs. There was significant variability in antibiotic prescribing practices by ED physicians. This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction.

Introduction: Patients with acute atrial fibrillation or flutter (AAFF) are the most common acute arrhythmia cases requiring care in the ED. Our goal was to adapt the existing Canadian Cardiovascular Society (CCS) AF Management Guidelines into an emergency physician-friendly best practices checklist. Methods: We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the CCS using the GRADE system. We used the Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. We created an Advisory Committee consisting of 14 academic and community emergency physicians, three cardiologists, one PhD methodologist, and two patients. The Advisory Committee communicated by a two-day face-to-face meeting, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues whose written feedback was further incorporated into the final approved version. Results: The final CAEP ED AAFF Guidelines are comprised of two algorithms and four sets of checklists, organized by 1) Assessment and Risk Stratification, 2) Rhythm and Rate Control, 3) Long-term Stroke Prevention with the CHADS-65 Algorithm, and 4) Disposition and Follow-up. The guidelines have been endorsed by CAEP and accepted for publication in the Canadian Journal of Emergency Medicine. During the consensus and feedback processes, we addressed a number of issues and concerns. We highlighted the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. One controversial recommendation is to consider rate control or transesophageal echocardiography guided cardioversion if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated. Conclusion: We have created the CAEP AAFF Best Practices Checklist which we hope will standardize and improve care of AAFF patients in all EDs across Canada. We believe that most of these patients can be managed rapidly and safely with ED rhythm control, early discharge, and appropriate use of anticoagulants.

Introduction: Acute atrial fibrillation (AAF) is the most common arrhythmia managed in the Emergency Department (ED). Direct costs of AAF are primarily attributed to ED visits and subsequent admission to hospital. A better understanding of patients attitudes regarding ED attendance is necessary to develop strategies to improve the patient care experience while simultaneously reducing ED presentation and inappropriate hospital admissions. This study aims to describe patient perspectives on ED use for AAF using in-depth qualitative interviews. Methods: An interview template designed to explore why patients attend the ED for AAF was constructed based on the Theoretical Domains Framework, a theory-informed approach that utilizes 14 domains to describe influencers of behavior. We conducted audio-recorded, semi-structured interviews of patients following their presentation to the ED for management of AAF. Interviews were anonymized, transcribed and imported into NVivo for coding and analysis. Two independent reviewers used a direct approach to code participant statements. Discrepancies were resolved by a third party. Belief statements were generated and relevant domains identified based on high frequency scores, conflicting belief statements or evidence of strong influencing beliefs. Results: 12 patient interviews, mean age 63.1 years, 91.7% male, 75.0% recurrent AAF, were completed. Patients stated that they attended the ED because: 1) symptom severity; 2) they were instructed by physicians to attend the ED should their AAF recur; and 3) they were encouraged by family members to attend. Their primary goal was to have relief of their symptoms. There was no expectation of specialist consultation or admission to hospital. Even though most patients stated they were open to managing these episodes independently, they reported that they did not have the knowledge or tools to do so. Conclusion: Patients with AAF present to the ED because of their symptom burden, social influences (physician and family) and lack of other management options. This study demonstrates the need for development of patient self-management strategies which will empower patients in their disease management and may decrease future ED visits.

Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.

Introduction: The Geriatric Emergency Management (GEM) model has been developed to facilitate identification of older patients that are at higher risk of functional decline, repeat Emergency Department (ED) visits and future hospitalization. Those identified at risk, are referred for more in-depth evaluation and management in community-based specialized geriatric services. Our objective was to: 1) determine the compliance rate to outpatient evaluation following ED recommendation; and 2) identify barriers and facilitators to attendance. Methods: We conducted a prospective cohort study at two sites of an academic, tertiary level hospital ED between July and December 2016. We enrolled a convenience sample of ED patients, 65 years and older who were seen by a GEM nurse, referred to outpatient specialized geriatric services and consented to study participation. The GEM nurses conducted targeted geriatric assessments, identifying those who would benefit from further community management. We conducted a chart review and a structured telephone follow-up at 6 weeks. Descriptive statistics were used. Results: A total of 101 patients were prospectively enrolled, with 30.4% of eligible participants declining outpatient referral. Enrolled subjects had a mean age of 83.3 years, 58.4% female and 62.0% cognitively impaired. Reasons for referral to specialized geriatric services included: mobility (86.1%), cognition (57.4%), pain (38.6%), mood (34.7%), medication management (33.6%) and nutrition (30.7%). Outpatient referrals were to: geriatric day hospital (51.5%), geriatric outreach (22.7%), falls clinic (11.8%) and geriatric psychiatry (9.9%). Compliance with follow-up within 6 weeks was 64.4%. Barriers to attendance included: patient did not feel specialized geriatric services was needed (52.6%); admitted to hospital (10.5%); reported not called for appointment (15.8%); forgot appointment (5.3%) and transportation (5.3%). Family support with scheduling and transportation to appointments, reported by 68.6%, was the most common enabler to compliance. Conclusion: Over one third of older ED patients referred by GEM for further specialized geriatric services are non-compliant with their community-based evaluation, while one in four older ED patients decline referral to these evaluations while in the ED. Future work should focus on interventions that promote increased referral acceptance and address barriers to attendance.

Introduction: Older patients are a high-risk population in the Emergency Department (ED) for poor outcomes after ED visit, including return presentation and hospital admission. Little is known however about outcomes in older patients identified as “low acuity” by triage. We aim to describe the characteristics, ED workup, disposition, and 14-day outcomes of ED patients 65 years and up who are triaged as low acuity and compare them to a younger cohort. Methods: This health records review was done in a Canadian tertiary care ED. Included patients received a Canadian Triage Acuity score (CTAS) of 4 or 5 and were either 65 years and up (“older” group), or 40-55 years (controls). Data collected included patient demographics, tests and services involved in ED, and disposition. Return ED visit and hospital admission rates at 14 days were tracked. Data were analyzed descriptively and chi-square testing conducted to assess for differences (p < 0.05) between groups. A pre-planned stratified analysis of patients 65-74 years, 75-84, and 85 and older was conducted. Results: 350 patients (mean age 76.5, 56.6% female) were included in the older group and 150 in the control group (mean age 47.3, 55.3% female). Most patients presented with musculoskeletal or skin complaints (older cohort: 28.6% extremity pain/injury, 10% rash, 8.9% laceration, versus control 30% extremity pain/injury, 14.7% rash, 14.0% laceration) and were triaged to the ambulatory care area (88.6% elderly, 99.3% control). Older patients were significantly more likely than younger controls to be admitted on index visit (5.0% vs 0.3% admit rate, p=0.016). They had a trend towards increased re-presentation rates within 14 days (13.7% vs 8.7% control, p=0.11) and were more likely to be admitted on re-presentation (4.0% vs 0.7%, p=0.045). In sub-group analysis, very elderly patients (85 years and up, n=79) were more likely to be admitted (8.9%, p=0.003). Conclusion: Patients 65 years of age and older who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients 85 years and up are the primary drivers of this higher admit rate. This study characterizes “low acuity” elders presenting to ED and indicates these patients are high risk for re-presentation and admission within 14 days.

Background: Patients with poorly controlled diabetes mellitus (DM) often visit the emergency department (ED) for management of hyperglycemic episodes, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It has been previously reported that risk factors for readmission to the intensive care unit (ICU) in DKA include older age, female sex and the presence of significant comorbidity including sepsis. However, there are no ED-based studies on this topic, particularly in a Canadian setting, and data on outcomes such as recurrent ED visits, hospital or ICU admission after discharge in these patients is lacking. Objectives: The primary objective of this study is to derive and internally validate a clinical risk tool for prognosis of patients presenting with hyperglycemic emergencies to identify those at higher risk of adverse outcomes within 30 days of initial ED presentation. Methods: This will be a multicentre prospective cohort study of eligible consecutive adult patients with an ED diagnosis of hyperglycemia, DKA or HHS. We will include all visits of adult (≥18 years) ED patients with either a known or unknown history of DM and a diagnosis of hyperglycemia (blood glucose >11.0 mmol/L), DKA or HHS. We will include patients with co-morbid diagnoses in addition to hyperglycemia. We will exclude patients: a) with advanced care directives for resuscitation involving refusal of treatment, and b) who are initially assessed at a peripheral hospital and transferred to our sites for ongoing management. Research assistants will then contact the enrolled participants via telephone for follow-up regarding clinical outcomes, including repeat visits to see a health care provider, changes in diabetic medications, and time taken off of work or school. Participants will be followed to determine if they have further ED visits, admissions or ICU admissions after their ED visit for hyperglycemia. Data on missed patients or those who refused consent will be collected to assess for selection/enrolment bias. Statistical considerations: The primary outcome will be an unplanned return ED visit for hyperglycemia within 30 days of initial presentation. Secondary outcomes will include unplanned admission to hospital or ICU for hyperglycemia, or death within 30 days of the index ED visit. Additionally, we hope to characterize patient-important and health-care system outcomes such as time taken off work or school and follow-up visits to see a healthcare provider. We will conduct descriptive statistics on investigations, treatments, disposition and patient-important outcomes. We will perform an initial univariate logistic regression, followed by a multivariate analysis to identify predictor variables associated with adverse events such as recurrent ED visits, and admission to hospital or ICU for hyperglycemia within 30 days. We will include individual patients who have multiple recurrent visits to the ED during the study period and statistically weight for these using generalized estimating equations (GEE), which are used to develop regression models for correlated data that arise from repeated measures of the same individuals over time. Finally, a clinical risk tool will be derived by rounding the beta co-efficients. Internal validation will be conducted using bootstrapping techniques. Importance: ED visits for hyperglycemia significantly affect both the healthcare system overall and the individual patient. The results of this project will assist clinicians to better identify these patients and enable them to intervene either medically or educationally to prevent subsequent visits to the ED. As a result, patients will have improved care, better blood glucose control, and be identified for closer follow-up with a family physician or diabetes specialist. Furthermore, by aiming to reduce the number of recurrent visits, this project may reduce ED utilization and the associated healthcare costs with frequent visits and admissions for hyperglycemia.

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The combined measure presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.

Background: The diagnosis of a sports-related concussion is often dependent on the athlete self-reporting their symptoms. It has been suggested that improving youth athlete knowledge and attitudes toward concussion may increase self-reporting behaviour. The objective of this study was to determine if a novel Concussion-U educational program improves knowledge of and attitudes about concussion among a cohort of elite male Bantam and Midget AAA hockey players. Methods: Fifty-seven male Bantam and Midget AAA-level hockey players (mean age=14.52±1.13 years) were recruited from the local community. Each participant completed a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey–Student Version immediately before and after a Concussion-U educational presentation. Follow-up sessions were arranged 4 to 6 months after the presentation, and assessed retention of knowledge and attitude changes. Results: Forty-three players completed all three surveys. Concussion knowledge and attitude scores significantly (p<0.01) increased from pre- to post-presentation by 12.79 and 8.41%, respectively. At long-term follow-up, knowledge levels remained significantly (p<0.01) higher than baseline by 8.49%. Mean attitude scores were also increased at follow-up; however, this increase was not statistically significant. Conclusions: A Concussion-U educational program led to an immediate improvement in concussion knowledge and attitudes among elite male Bantam and Midget AAA hockey players. Increased knowledge was maintained at long-term follow-up, but improved attitude was not. Future studies should investigate whether similar educational programs influence symptom reporting and concussion incidence. In addition, they should focus on how to maintain improved concussion attitudes.

Background: Research has suggested that female athletes have a higher incidence of concussion compared to their male counterparts. As such, programs designed to improve knowledge and attitudes of concussion should target this high-risk population. Previous work demonstrated the effect of a novel Concussion-U educational presentation on knowledge and attitudes of concussion amongst male Bantam and Midget AAA hockey players. The objective of this study was to determine if the same presentation was effective in improving the knowledge and attitudes of concussion in a cohort of elite female hockey players. Methods: 26 elite female high-school aged (14-17) hockey players from the province of New Brunswick consented to participate in the study. Each participant completed a modified version of Rosenbaum and Arnett’s Concussion Knowledge and Attitudes Survey questionnaire immediately before and after a Concussion-U educational presentation. Results were compared across the two time-points to assess the effectiveness of the presentation. Results: Concussion knowledge and attitude scores significantly (p<.001) increased from pre-presentation to post-presentation by 12.5% and 13.4%, respectively. Conclusions: A Concussion-U educational presentation resulted in increased knowledge and improved attitudes towards concussion in elite female hockey players. Future research should examine the long-term retention of these improvements.

Background: The diagnosis of a concussion is often dependent on the athlete self-reporting their symptoms. It has been suggested that improving athlete’s knowledge and attitudes towards concussions may increase self-reporting behavior; however, research in this area is inconclusive. The objective of this study is to determine if a Concussion-U educational presentation improves knowledge and attitudes of youth hockey players towards concussions. This is part of a larger study designed to determine the impact of an informational presentation on the knowledge and attitudes over a full hockey season. Methods: 56 elite male Bantam and Midget hockey players (mean age=14.52±1.13 years) were recruited from the local community. Each participant completed a modified version of Rosenbaum and Arnett’s Concussion Knowledge and Attitudes Survey (RoCKAS) questionnaire immediately before and after a Concussion-U educational presentation on the subject. Results: Concussion knowledge and attitude scores significantly (p<.001) increased from pre-presentation to post-presentation by 13.1% and 8.7%, respectively. Discussion: A Concussion-U educational presentation designed to improve concussion knowledge and attitudes in youth hockey players resulted in increased knowledge and improved attitudes towards concussion in elite male Bantam and Midget hockey players. Future research should examine the long-term effects of such presentations.