The radiocarbon (14C) calibration curve so far contains annually resolved data only for a short period of time. With accelerator mass spectrometry (AMS) matching the precision of decay counting, it is now possible to efficiently produce large datasets of annual resolution for calibration purposes using small amounts of wood. The radiocarbon intercomparison on single-year tree-ring samples presented here is the first to investigate specifically possible offsets between AMS laboratories at high precision. The results show that AMS laboratories are capable of measuring samples of Holocene age with an accuracy and precision that is comparable or even goes beyond what is possible with decay counting, even though they require a thousand times less wood. It also shows that not all AMS laboratories always produce results that are consistent with their stated uncertainties. The long-term benefits of studies of this kind are more accurate radiocarbon measurements with, in the future, better quantified uncertainties.

The nature of schizophrenia spectrum disorders with an onset in middle or late adulthood remains controversial. The aim of our study was to determine in patients aged 60 and older if clinically relevant subtypes based on age at onset can be distinguished, using admixture analysis, a data-driven technique. We conducted a cross-sectional study in 94 patients aged 60 and older with a diagnosis of schizophrenia or schizoaffective disorder. Admixture analysis was used to determine if the distribution of age at onset in this cohort was consistent with one or more populations of origin and to determine cut-offs for age at onset groups, if more than one population could be identified. Results showed that admixture analysis based on age at onset demonstrated only one normally distributed population. Our results suggest that in older schizophrenia patients, early- and late-onset ages form a continuum.

Introduction: There is ongoing concern about the burden placed on healthcare systems by lab tests. Although these concerns are widespread, it is difficult to quantify the extent of the problem. One approach involves use of a metric known as the Mean Abnormal Response Rate (MARR), which is the proportion of tests ordered that return an abnormal result; a higher MARR value indicates higher yield. The primary objective of this study was to calculate MARRs for tests ordered between April 2014 and March 2019 at the four adult emergency departments (EDs) covering a metropolitan population of 1.3 million. Secondary objectives included identifying tests with highest and lowest MARRs; comparison of MARRs for nurse- and physician-initiated orders; correlation of the number of tests per order requisition to MARR; and correlation of physician experience to MARR. Methods: In total, 40 laboratory tests met inclusion criteria for this study. Administrative data on these tests as ordered at the four EDs were obtained and analyzed. Multi-component test results, such as from CBC, were consolidated such that an abnormal result for any component was coded as an abnormal result for the entire test. Repeat tests ordered within a single patient visit were excluded. Physician experience was quantified for 209 ED physicians as number of years since licensure. Analyses were descriptive where appropriate for whole-population data. Risk of bias was attenuated by the focus on administrative data. Results: The population dataset comprised 33,757,004 test results on 415,665 unique patients. Of these results, 30.3% were the outcomes of nurse-initiated orders. The 5-year MARRs for the four hospitals were 38.3%, 40.0%, 40.7% and 40.9%. The highest per-test MARRs were for BNP (80.5%) and CBC (62.6%), while the lowest were for glucose (7.9%) and sodium (11.6%). MARRs were higher for nurse-initiated orders than for physician-initiated orders (44.7% vs. 38.1%), likely due to the greater order frequency of high-yield CBC in nurse-initiated orders (38.6% vs. 18.1%). The number of tests per order requisition was inversely associated with MARR (r = -0.90, p < 0.001). Finally, the number of years since licensure was modestly but significantly associated with MARR (r = 0.28, p < 0.001). Conclusion: This is the first and largest study to apply the MARR in an ED setting. As a metric, MARR effectively identifies differences in test ordering practices on per-test and per-hospital bases, which could be useful for data-informed practice optimization.

Introduction: Mild Traumatic Brain Injury (mTBI) is a common problem: each year in Canada, its incidence is estimated at 500-600 cases per 100 000. Between 10 and 56% of mTBI patients develop persistent post-concussion symptoms (PPCS) that can last for more than 90 days. It is therefore important for clinicians to identify patients who are at risk of developing PPCS. We hypothesized that blood biomarkers drawn upon patient arrival to the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and the incidence of PPCS 90 days post mTBI. Methods: Patients were recruited in seven Canadian ED. Non-hospitalized patients, aged ≥14 years old with a documented mTBI that occurred ≤24 hrs of ED consultation, with a GCS ≥13 at arrival were included. Sociodemographic and clinical data as well as blood samples were collected in the ED. A standardized telephone questionnaire was administered at 90 days post ED visit. The following biomarkers were analyzed using enzyme-linked immunosorbent assay (ELISA): S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial fibrillary acidic protein (GFAP). The primary outcome measure was the presence of persistent symptoms at 90 days after mTBI, as assessed using the Rivermead Post-Concussion symptoms Questionnaire (RPQ). A ROC curve was constructed for each biomarker. Results: 1276 patients were included in the study. The median age for this cohort was 39 (IQR 23-57) years old, 61% were male and 15% suffered PPCS. The median values (IQR) for patients with PPCS compared to those without were: 43 pg/mL (26-67) versus 42 pg/mL (24-70) for S100B protein, 50 pg/mL (50-223) versus 50 pg/mL (50-199) for NSE, 2929 pg/mL (1733-4744) versus 3180 pg/mL (1835-4761) for c-Tau and 1644 pg/mL (650-3215) versus 1894 pg/mL (700-3498) for GFAP. For each of these biomarkers, Areas Under the Curve (AUC) were 0.495, 0.495, 0.51 and 0.54, respectively. Conclusion: Among mTBI patients, S100B protein, NSE, c-Tau or GFAP during the first 24 hours after trauma do not seem to be able to predict PPCS. Future research testing of other biomarkers is needed in order to determine their usefulness in predicting PPCS when combined with relevant clinical data.

Introduction: Compared to other areas in Alberta Health Services (AHS), internal data show that emergency departments (EDs) and urgent care centres (UCCs) experience a high rate of workforce violence. As such, reducing violence in AHS EDs and UCCs is a key priority. This project explored staff's lived experience with patient violence with the goal of better understanding its impact, and what strategies and resources could be put in place. Methods: To obtain a representative sample, we recruited staff from EDs and a UCC (n = 6) situated in urban and rural settings across Alberta. As the interviews had the potential to be upsetting, we conducted in-person interviews in a private space. Interviews were conducted with over 60 staff members including RNs, LPNs, unit clerks, physicians, and protective services. Data collection and analysis occurred simultaneously and iteratively until saturation was reached. The analysis involved data reduction, category development, and synthesis. Key phrases and statements were first highlighted. Preliminary labels were then assigned to the data and data was then organized into meaningful clusters. Finally, we identified common themes of participants’ lived experience. Triangulation of sources, independent and team analysis, and frequent debriefing sessions were used to enhance the trustworthiness of the data. Results: Participants frequently noted the worry they carry with them when coming into work, but also said there was a high threshold of acceptance dominating ED culture. A recurring feature of this experience was the limited resources (e.g., no peace officers, scope of security staff) available to staff to respond when patients behave violently or are threatening. Education like non-violent crisis intervention training, although helpful, was insufficient to make staff feel safe. Participants voiced the need for more protective services, the addition of physical barriers like locking doors and glass partitions, more investment in addictions and mental health services (e.g., increased access to psychiatrists or addictions counsellors), and a greater shared understanding of AHS’ zero tolerance policy. Conclusion: ED and UCC staff describe being regularly exposed to violence from patients and visitors. Many of these incidents go unreported and unresolved, leaving the workforce feeling worried and unsupported. Beyond education, the ED and UCC workforce need additional resources to support them in feeling safe coming to work.

Introduction: Emergency Departments (EDs) are at high risk of workforce-directed violence (WDV). To address ED violence in Alberta Health Services (AHS), we conducted key informant interviews to identify successful strategies that could be adopted in AHS EDs. Methods: The project team identified potential participants through their ED network; additional contacts were identified through snowball sampling. We emailed 197 individuals from Alberta (123), Canada (46), and abroad (28). The interview guide was developed and reviewed in partnership with ED managers and Workplace Health and Safety. We conducted semi-structured phone interviews with 26 representatives from urban and rural EDs or similar settings from Canada, the United States, and Australia. This interview process received an ARECCI score of 2. Two researchers conducted a content analysis of the interview notes; rural and urban sites were analyzed separately. We extracted strategies, their impact, and implementation barriers and facilitators. Strategies identified were categorized into emergent themes. We aggregated similar strategies and highlighted key or unique findings. Results: Interview results showed that there is no single solution to address ED violence. Sites with effective violence prevention strategies used a comprehensive approach where multiple strategies were used to address the issue. For example, through a violence prevention working group, one site implemented weekly violence simulations, a peer mentorship support team, security rounding, and more. This multifaceted approach had positive results: a decrease in code whites, staff feeling more supported, and the site no longer being on union “concerned” lists. Another promising strategy included addressing the culture of violence by increasing reporting, clarifying policies (i.e., zero tolerance), and establishing flagging or alert systems for visitors with violent histories. Physician involvement and support was highly valued in responding to violence (e.g., support when refusing care, on the code white response team, flagging). Conclusion: Overall, one strategy is not enough to successfully address WDV in EDs. Strategies need to be comprehensive and context specific, especially when considering urban and rural sites with different resources available. We note that few strategies were formally evaluated, and recommend that future work focus on developing comprehensive metrics to evaluate the strategies and define success.

Introduction: Clinical assessment of patients with mTBI is challenging and overuse of head CT in the emergency department (ED) is a major problem. During the last decades, studies have attempted to reduce unnecessary head CTs following a mTBI by identifying new tools aiming to predict intracranial bleeding. S100B serum protein level might be helpful reducing those imaging since a higher level of S-100B protein has been associated with intracranial hemorrhage following a mTBI in previous literature. The main objective of this study was to assess whether the S100B serum protein level is associated with clinically important brain injury and could be used to reduce the number of head CT following a mTBI. Methods: This prospective multicenter cohort study was conducted in five Canadian ED. MTBI patients with a Glasgow Coma Scale (GCS) score of 13-15 in the ED and a blood sample drawn within 24-hours after the injury were included. S-100B protein was analyzed using enzyme-linked immunosorbent assay (ELISA). All types of intracranial bleedings were reviewed by a radiologist who was blinded to the biomarker results. The main outcome was the presence of clinically important brain injury. Results: A total of 476 patients were included. Mean age was 41 ± 18 years old and 150 (31.5%) were female. Twenty-four (5.0%) patients had a clinically significant intracranial hemorrhage while 37 (7.8%) had any type of intracranial bleeding. S100B median value (Q1-Q3) of was: 0.043 ug/L (0.008-0.080) for patients with clinically important brain injury versus 0.039 μg/L (0.023-0.059) for patients without clinically important brain injury. Sensitivity and specificity of the S100B protein level, if used alone to detect clinically important brain injury, were 16.7% (95% CI 4.7-37.4) and 88.5% (95% CI 85.2-91.3), respectively. Conclusion: S100B serum protein level was not associated with clinically significant intracranial hemorrhage in mTBI patients. This protein did not appear to be useful to reduce the number of CT prescribed in the ED and would have missed many clinically important brain injuries. Future research should focus on different ways to assess mTBI patient and ultimately reduce unnecessary head CT.

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.

Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures & Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.

Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.

Introduction: Mild traumatic brain injury (mTBI) is a serious public health issue and as much as one third of mTBI patients could be affected by persistent post-concussion symptoms (PPCS) three months after their injury. Even though a significant proportion of all mTBIs are sports-related (SR), little is known on the recovery process of SR mTBI patients and the potential differences between SR mTBI and patients who suffered non-sports-related mTBI. The objective of this study was to describe the evolution of PPCS among patients who sustained a SR mTBI compared to those who sustained non sport-related mTBI. Methods: This Canadian multicenter prospective cohort study included patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of Emergency Department (ED) visit, with a Glasgow Coma Scale score of 13-15. Patients who were hospitalized following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. Three follow-up phone interviews were conducted by a research nurse at 7, 30 and 90 days post-injury to assess symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to demonstrate the impact of the mechanism of injury (sports vs non-sports) on the presence and severity of PPCS. Results: A total of 1676 mTBI patients were included, 358 (21.4%) of which sustained a SR mTBI. At 90 days post-injury, patients who suffered a SR mTBI seemed to be significantly less affected by fatigue (RR: 0.70 (95% CI: 0.50-0.97)) and irritability (RR: 0.60 (95% CI: 0.38-0.94)). However, no difference was observed between the two groups regarding each other symptom evaluated in the RPQ. Moreover, the proportion of patients with three symptoms or more, a score ≥21 on the RPQ and those who did return to their normal activities were also comparable. Conclusion: Although persistent post-concussion symptoms are slightly different depending on the mechanism of trauma, our results show that patients who sustained SR-mTBI could be at lower risk of experiencing some types of symptoms 90 days post-injury, in particular, fatigue and irritability.

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.