Introduction: Recently, campaigns placing considerable emphasis on improving emergency department (ED) care by reducing unnecessary tests, treatments, and/or procedures have been initiated. This study explored how Canadian emergency physicians (EPs) conceptualize unnecessary care in the ED. Methods: An online 60-question survey was distributed to EP-members of the Canadian Association of Emergency Physicians (CAEP) with valid emails. The survey explored respondents awareness/support for initiatives to improve ED care (i.e., reduce unnecessary tests, treatments and/or procedures) and asked respondents to define “unnecessary care” in the ED. Thematic qualitative analysis was performed on these responses to identify key themes and sub-themes and explore variation among EPs definitions of unnecessary care. Results: A total of 324 surveys were completed (response rate: 18%); 300 provided free-text definitions of unnecessary care. Most commonly, unnecessary ED care was defined as: 1) performing tests, treatments, procedures, and/or consults that were not indicated or potentially harmful (n=169) and/or 2) care that should have been provided within a non-emergent context for a non-urgent patient (n=143). Emergency physicians highlighted the role of system-level factors and system failures that result in ED presentations as definitions of unnecessary care (n=69). They also noted a distinction between providing necessary care for a non-urgent patient and performing inappropriate/non-evidenced based care. Finally, a tension emerged in their description of frustration with patient expectations (n=17) and/or non-ED referrals (n=24) for specific tests, treatments, and/or procedures. These frustrations were juxtaposed by participants who asserted that “in a patient-centred care environment, no care is unnecessary” (Participant 50; n=12). Conclusion: Variation in the definition of unnecessary ED care is evident among EPs and illustrates that EPs’ conceptualization of unnecessary care is more nuanced than current campaigns addressing ED care improvements represent. This may contribute to a perceived lack of uptake or support for these initiatives. Further exploring EPs perceptions of these campaigns has the potential to improve EP engagement and influence the language utilized by these programs.

Introduction: Although Tenofovir/Emtricitabine was approved in 2012 as a single-agent regimen for pre-exposure prophylaxis, there have been no studies to our knowledge that demonstrate the efficacy of single and dual agent regimens in post-exposure prophylaxis. Our goal was to compare outcomes of post-exposure prophylaxis with single and dual agent regimens versus triple therapy in victims of sexual assault. Methods: This was a before and after cohort study of patients seen by the Sexual Assault and Partner Abuse Care Program (SAPACP) at the Ottawa Hospital. We reviewed charts of patients seen by the SAPACP from Jan. 1-Dec. 31 2013, when triple therapy was usual care, and Jan. 1-Dec. 31 2015, after the introduction of alternative regimens. Patients who were deemed high risk or who did not get initial treatment at the SAPACP were excluded. Our primary outcome was the number of patients who completed the entire 28-day post-exposure prophylaxis regimen. Secondary objectives were to assess HIV seroconversion rates and patient reported side effects. Results: Six hundred-thirty charts were reviewed, and 429 were included in the study. Baseline characteristics were similar between the two years. We found no significant difference in completion rates of HIV post-exposure prophylaxis between the two cohorts (50.5% vs. 51.6%). However, we did note a decrease in reported side effects in the 2015 cohort (72.2% vs. 17.6%, p<0.0001). In our secondary analysis, we compared all patients in all years who received triple therapy (N=128) versus those who received alternative single or dual agent regimens (N=47). We found that the alternative regimen group had a higher completion rate (66.0% vs. 42.2%; p=0.03), and a dramatic decrease in rate of reported side effects (19.1% vs. 53.9%; p<0.0001). Specifically, we saw decreased reported rates of nausea (12.8% vs. 36.7 %), constipation (0% vs. 7.9%), diarrhea (2.1% vs. 21.1%), mood changes (0% vs. 10.9%), headache (2.1% vs. 16.4%), and fatigue (6.4% vs. 26.6%). There were no HIV seroconversions in either group. Conclusion: Our results suggest that single and dual agent HIV post-exposure prophylaxis regimens are better tolerated by patients and associated with higher rates of completion than triple therapy, and should be considered as stand-alone therapy in the sexual assault victim population.

Introduction: Pulmonary Embolism (PE) is a difficult to diagnose presentation associated with significant morbidity and mortality. Despite development of risk stratification tools (RST), physician gestalt continues to play a large role in the diagnostic evaluation of PE. Implicit in this gestalt is the evaluation of PE risk factors (RF). It is unknown, however, if physicians are similar and accurate in their assessment of known PE RF. Methods: An online survey presented paired comparisons (n=55) of 11 known PE RF to active Emergency Physicians (n=20), Family Doctors (n=11), and Residents (Family Medicine [n=20]; Emergency Medicine [n=5]). The Bradley-Terry Model converted the paired comparisons to rank order lists for the cohorts and these lists were compared. The perceived efficacy and use of RST and gestalt was also assessed across the cohorts. Results: The response rate was 72%. Emergency Physicians had the highest perception of gestalt as an effective method of risk stratification (7.4±1.4 out of 10) while Family Medicine Residents had the lowest (5.1±1.9). More than 95% of Emergency Physicians and Residents employed RST (PERC and Wells) compared to 46% of Family Physician respondents. Those who used RST utilized the tools in the majority of their clinical encounters (>75% of the time). There was good agreement between the cohorts in regards to their rank order lists (Tau-b ≥ 0.71). Age was identified as a RF which was consistently ranked lower than literature reported values amongst the cohorts. Conclusion: Physicians in various practice settings and levels of training rank PE risk factors similarly when forced to compare them. There are important RF, most notably age, which were identified in the current study that were consistently undervalued. This finding may highlight how RST are shaping perceptions of PE RF through their use and how age as a PE RF may warrant more attention in education and clinical assessments.

Introduction: The Oral Case Presentation (OCP) has been described as a unique form of inter-physician communication integral to the practice of medicine and represents the foundation of trainee-supervisor interactions. In recent years, entrustment has been identified as an essential element of trainee supervision and learning. Despite the growing body of knowledge concerning entrustment in medical education, the influence of trust on the educational dynamic surrounding the OCP remains unknown. The objectives of this study were to (1) describe the complex nature of the OCP from the perspective of the supervisor and (2) explore the central role the OCP plays in the dyadic relationship between supervisor and trainee during the delivery of patient care. Methods: Using a constructivist grounded theory approach, semi-structured interviews were conducted from 2015 to 2016 with a purposive sample of attending Emergency Medicine (EM) physicians from the University of Ottawa. Transcripts were reviewed independently by two investigators using line-by-line coding and constant comparative analysis. Emerging concepts were coded and key themes identified through consensus. Theoretical sampling occurred until thematic saturation was reached. Results: Twenty-one attending EM physicians participated in this study (71% male). The mean number of years in practice was 14. The mean percentage of shifts with a trainee assigned was 86%. Factors relating to entrustment were identified as the principal influences on both the content of the OCP and decisions relating to trainee supervision during the OCP process. These factors included the trainee level, the trainee-supervisor relationship, the context and the task. The OCP was also found to play several important roles as supervisors balanced the delivery of patient care and trainee education. These roles were related to communication, teaching and trainee assessment. Conclusion: The OCP represents a core activity within the supervisor-trainee relationship in which trust plays a central role. Clinical supervisors value the OCP as a form of authentic assessment of skills and perceive it to be a key determinant in making entrustment decisions. Future studies designed to evaluate the utility of the OCP as an educational tool should consider entrustment as an essential element.

Introduction: With rising health care costs impairing access to care, the judicious use of diagnostic tests has become a critical issue for most jurisdictions. Among tests regularly performed in the emergency department (ED), calcium (Ca), magnesium (Mg) and phosphorus (P) laboratory testing represents an annual expenditure of more than $4 million for the Québec health care system. We then sought to determine the best indications for ordering these serum levels by identifying patient risk factors predicting abnormal results. Methods: We are conducting a retrospective cohort study in two academic hospitals of Québec City, one providing acute general care and the other providing specialized care to oncologic and nephrologic patients. We included 1000 patients who had serum Ca and/or Mg and/or P levels prescribed by an emergency physician between January 1st 2016 and May 1st 2016. We are collecting demographic (e.g. age) and clinical (e.g. comorbidities) characteristics identified from literature review as potential explanatory variables of an abnormal serum level. Predictive models of a positive test result will be derived from logistic regressions. Results: We have evaluated 143 patients. ED prevalence rates of hypo- and hyper-calcemia (10.1% and 4,3%), hypo- and hyper-magnesemia (13.0% and 7,2%), hypo- and hyper-phosphatemia (9.5% and 13,9%) were similar to those reported in literature. Preliminary bivariate analysis (p<0.05) have shown that, for patients who had serum Ca/Mg/P levels prescribed, one in four complained of weakness, one in five complained of abdominal pain and one in five presented on physical examination an abnormal mental status. Acute and chronic renal failure appears to be a strong predictor of anomalies of any of those electrolytes. Neoplasia, metastasis, hallucinations, bone pain and confusion are more specifically associated with hypercalcemia. Use of corticosteroids is associated with hypocalcemia. Conclusion: Our bivariate analyses have identified potential risk factors of abnormal Ca/Mg/P results. Multivariate logistic regressions will be conducted on the complete planned cohort to further test these preliminary results.

Introduction: Lors d’un traumatisme cranio-cérébral léger, les complications hémorragiques sont rares et ne nécessitent qu’exceptionnellement une intervention neurochirurgicale (<1%). Dans le but de limiter les radiations inutiles et les coûts, Choosing Wisely s’est récemment positionnée avec CAEP afin de recommander l’usage de la Canadian CT Head Rule (CCHR) suite un à TCCL. L’objectif principal de cette étude vise à évaluer l’observance des médecins d’urgence concernant l’utilisation de la règle CCHR chez les patients ayant subi un TCCL. L’objectif secondaire consiste à identifier les facteurs associés au risque de non-observance dans cette situation clinique. Methods: Des analyses univariées et multivariées ont été effectuées sur les données de 854 patients ayant subi un TCCL et ayant été recrutés dans les 24 heures suivant leur visite dans un centre tertiaire québécois de traumatologie. Des analyses descriptives ont permis d’estimer la proportion de médecins d’urgence ayant utilisé les critères de la règle CCHR et ceux n’ayant pas été observants. Nous avons ensuite évalué les facteurs potentiellement associés au risque de non-observance. Results: 62.9% des patients avec TCCL ont subi une TDM au département d’urgence. La non observance globale des médecins face à la règle était de 29.9%. De plus, la proportion de TDM effectuée sans indication selon la règle est égale à 20% (177/854). Les facteurs suivants semblent associés au risque de surutilisation de la TDM: la prise d’acide acétylsalicylique (RR=1.8, [IC 1.3-2.6]), la présence de céphalée décrite par le patient au moment de l’évaluation (RR=1.5, [IC 1.2-1.9]), et l'âge (55-64 ans versus moins de 55 ans) (RR=1.6 [IC 1.2-1.9]). Conclusion: L’évaluation de l’observance des médecins face à ces recommandations, combinée à l’identification des facteurs en cause lors de la non-observance favoriseront une meilleure orientation des interventions de transfert de connaissances dans le futur en plus d’améliorer la qualité des soins et l’efficience des ressources.

Introduction: Mild traumatic brain injury (mTBI) is a common problem and until now, ED physicians don’t have any tool to predict when the patient will return to work. The purpose of this study is to develop and validate a clinical decision rule to identify the ED patients who are at risk of non-return to work or to school three months after a mTBI. Methods: Patients were recruiting in five Level I and II Trauma Centers ED in the province of Québec. All patients were referred for a systematic telephone follow-up after three months. Information about their return to work/school, partial or complete, was collected. Log binomial regression was used to develop a predictive model and the validation of this model was performed on a different prospective cohort. Results: 13,7% of the patients did not return to work/school at three months. The final model was derived from a prospective cohort of 398 patients and included three risk factors: motor vehicle accident (2 points), loss of consciousness (1 point) and headache during the emergency department assessment (1 point). With a one-point threshold, this model has a sensitivity of 97% and a negative predictive value (NPV) of 98%. However, the specificity is only 23% and the positive predictive value (PPV) is 17%. The area under the curve is 0.786. Validation of the model was performed with a new prospective cohort of 517 patients, and demonstrated a sensitivity of 86% and a NPV of 91%. Conclusion: Although this model is not very specific, its high sensitivity and NPV indicate to the clinician that mTBI patients who don’t have any of the three criteria are at low risk of prolonged work stoppage after their trauma.

Introduction: Point-of-care-ultrasound is an established tool in the early diagnosis of abdominal aortic aneurysm (AAA), with a reported pooled sensitivity of 97.5% and pooled specificity 98.9%. Despite these impressive numbers, body habitus and bowel gas often render emergency department (ED) PoCUS for AAA inconclusive. We devised a manual aid “the modified peace sign technique” to improve visualization of the aorta, consisting of placing the divided fingers of the free hand of the sonographer around the probe to increase gas dispersion and improve the view of the obscured aorta. We tested the technique on volunteers during a training course when the initial scan was indeterminate due to inability to view the aorta from sub-xiphoid to bifurcation. Methods: In our pilot study, 7 physicians were asked to make a best attempt to perform an aortic scan. If they were unable to visualize the aorta, they were asked to use the modified peace sign technique. Participants recorded the number of times which they used the technique and the frequency that the technique allowed for a complete aortic scan, previously unobtainable. All scans were supervised by certified PoCUS physicians. Results: The technique was used a total of 25 times. Following failure to complete an aortic scan using their best attempt, participants were subsequently able to obtain a complete aortic scan 70% (95% CI 48 to 83%) of the time using the modified peace sign technique. Conclusion: In our pilot study, the modified peace sign technique had an estimated effect size of 70% improvement for visualization of the aorta in volunteers. Further studies are required to validate the technique in clinical practice.

Introduction: Paramedics are often required to manage violent or combative patients. In order to do so safely, chemical sedation may be required. There are a number of pharmacologic agents which may be used. However, there is a paucity of evidence as to the optimal agent. Objective: To provide a descriptive analysis of a single base hospital’s experience with combative patients and to determine the efficacy and any adverse events (AEs) in the prehospital setting, associated with midazolam use in these patients. Methods: A retrospective chart review of ambulance calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were filtered and manually examined. Patients were excluded if they were 17 or younger. A priori data points were abstracted by trained research personnel from the ambulance call record. Results: Of approximately 350,000 calls over the study period, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam for sedation. Multiple doses were required in 33.3% of patients. Depending on route of administration, the average total dose administered was 6.27 mg (SD 3.98 mg) intramuscular, 10.7 mg (SD 4.00 mg) intranasal and 4.95 mg (SD 3.81 mg) intravenous. Midazolam was documented as effective in treating the combativeness in 133 (71.6%), ineffective in 28 (15.1%), and not documented in 25 (13.4%) calls. AEs post midazolam administration, defined as hypotension, bradypnea, bradycardia, or need for airway intervention, were encountered in 3 (1.61%) calls (respiratory rate of 8, hypotension of 88/59 that responded to intravenous fluid and asymptomatic bradycardia of 59). There was a trend of increasing number of combative patients each year over the study period, with a significant difference in the number of combative calls requiring midazolam administration between 2012 and 2015 (50.0% vs 72.8%, p=0.007). Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with minimal AEs. However, midazolam was ineffective in 15.1% and a third of all patients required multiple doses, prolonging the combative period and compromising paramedic and patient safety. Further research is warranted for this cohort’s emergency department (ED) sedation needs and any associated AEs within 1 hour of ED arrival.

Introduction: Paramedics are required to manage combative patients. In order to do so safely, chemical sedation may be required. Advanced Care Paramedics in our EMS system utilize midazolam for chemical restraint. Our previous research has shown that midazolam appears to have few prehospital adverse events (AEs) associated with its use. However, it required multiple dosages in 33.3% of patients and was deemed ineffective in 15.1% of patients that received it in the prehospital setting. Objective: To determine Emergency Department (ED) AEs associated with the prehospital use of midazolam in combative patients and determine the efficacy of this agent as a chemical restraint during the first hour of the ED stay. Methods: A retrospective chart review of paramedic calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were examined. Patients were excluded if they were 17 or younger. Ambulance call records were linked to the patient’s ED chart. ED charts were reviewed and a priori endpoints were extracted. Results: Of approximately 350,000 calls, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam in the prehospital setting. During the first hour of their ED stay, 68 (36.5%) required further sedation, while 118 (63.4%) patients did not. Of the 186 patients who received midazolam in the prehospital setting there was one death and one AE in the ED (defined as hypotension, bradypnea, or need for airway intervention). After further review of the charts, both AEs were deemed likely resulting from underlying pathology and not related to the use of midazolam. The average ED Length of stay (LOS) was 7.6 hours for all patients. A total of 82 (44.1%) were admitted to hospital with a mean in hospital LOS of 13.1 days. Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with no reported delayed AEs. 36.5% of this cohort required further sedation within 1 hour of their ED arrival. This supports previous findings that midazolam was ineffective in 15.1 % of prehospital combative patients. Further study is required to determine midazolam’s efficacy and AE profile compared to other prehospital agents in order to ensure optimal safety of both patients and paramedics.

Introduction: Point of care ultrasound (POCUS) has many applications in Emergency Medicine which are proven to improve patient outcomes. Training programs and guidelines for its use are available but its utilization metrics across Canadian Emergency Departments are unknown. This study aims to provide a comprehensive national assessment of POCUS usage, with a key component comparing training with patterns of use. Methods: A survey was distributed via email to all staff adult emergency physician members of the Canadian Association of Emergency Physicians (CAEP). The survey included questions related to training, attitudes towards POCUS, POCUS utilization, and barriers to POCUS use. Standard descriptive statistics were calculated, and differences in mean POCUS usage between groups were measured using a one-way analysis of variance (ANOVA). Results: The survey received 189 responses from emergency physicians from across Canada, 81% of which viewed POCUS as “useful and essential”. Respondents indicated that on average, POCUS was used during 71% (SD 29%) of shifts and on 23% (SD 17%) of patients. POCUS was most commonly used for basic applications, including thoracoabdominal trauma (FAST), cardiac assessment in arrest (trans-abdominal), and assessing for pericardial effusion. The most commonly cited barrier to wider POCUS adoption was a lack of training, with 41% of respondents identifying this as an issue. Correspondingly, formal POCUS training and certification were associated with significantly higher POCUS usage: usage rates ranged from 11.5% (SD 10.5%) of patients for those with formal training but no certification to 39.5% (SD 16.4%) of patients for those with a POCUS fellowship (p <0.001). Conclusion: The presented results from this survey provide an initial overview of the current state of POCUS usage in Canadian Emergency Departments. In summary, a higher level of training was associated with higher POCUS usage, and over a third of the respondents cited lack of training as a barrier to adoption; this suggests that efforts to facilitate POCUS utilization should focus on improving access to formal training and certification. Future work will involve further evaluation of additional barriers preventing POCUS usage in the ED, with the goal of providing information that will encourage changes that support widespread POCUS adoption.

Introduction: The Surviving Sepsis Campaign (SSC) suggests that hypovolemic patients, in the setting of hypoperfusion, be administered 30 mL/kg crystalloid fluid within the first 3 hours of presentation to hospital. More recent evidence suggests that fluid resuscitation within 30 min of sepsis identification is associated with reduced mortality, hospital length of stay and ICU days. This study describes Emergency Department (ED) fluid resuscitation of patients with septic shock and/or sepsis-related in-hospital mortality, prior to implementation of a sepsis medical directive. Methods: Retrospective chart review of adult patients (18+ years), presenting to two tertiary care EDs between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis. Data were abstracted from electronic health records. Patients with septic shock, or who expired in the ED/hospital, were selected for manual chart review of clinical variables including: time, type and volume of ED IV fluid administration. Results: 13,506 patient encounters met inclusion criteria. In-hospital mortality rates were 2% (sepsis), 11.5% (severe sepsis), and 24.1% (septic shock). Of patients hypotensive at triage, fluids were administered to 33/50 (66.00%) septic shock patients, and 22/43 (51.16 %) patients who eventually expired. For all septic shock and expired patients (943), median time to IV fluid initiation was 60.50 minutes [29.75 to 101.25] for septic shock and 77.00 minutes [36.00 to 127.00] for expired patients. Median volume of fluid administered was 1.50L [1.0 to 2.00] for septic shock and 1.00L [1.00 to 2.00] for expired patients. Of septic shock and expired patients, IV fluid administration and body weight data was available for 148 encounters (15.6%). Within this group, 19 (12.8%) received no IV fluid. 90 (60.8%) received 0.1-75% of their recommended IV fluid volume. 25 (16.9%) received 75.1-125%, and 14 (9.4%) received >125.1% of their recommended fluid volume. Conclusion: In this study, severe forms of sepsis were often treated with <30 mL/kg crystalloid fluid. Fluids were administered outside of the recommended 30 min, but within the 3 h, time windows. In-hospital mortality was consistent with published data. Future research will examine a broader data set for IV fluid resuscitation in sepsis, and will measure the impact of a fluid resuscitation in sepsis medical directive.

Introduction: Barriers to implementing effective Knowledge Translation (KT) in Emergency Departments include lack of awareness, lack of time and limited access to resources. In our teaching hospital emergency department (ED), we implemented a new department website (www.sjrhem.ca) to provide improved access to our KT resources. Having published the website, we wanted to know if the addition of conveniently situated pre-configured iPads would increase access to the website from within the department. Methods: The website was developed and first published in April 2014. Two iPads (Apple Inc.) were preconfigured with icons linking directly to targeted pages on our website, including the physician schedule, academic calendar. The iPads were securely located at physician charting desks in October 2014. We used Google analytics to record of webpage visits for 25 weeks before and after the installation of the iPads. Comparisons of mean weekly visits were made using the Student T test (GraphPad Prism). Results: The mean weekly page views for the website increased after the installation of the iPads from a baseline of 103 (95%CI 83.9-121) to 198 (181-215); an increase of 95% (71-120; p<0001). Limiting analysis to devices utilising our hospital IP address we saw a 403% increase in mean weekly page views from 6.4 (4.35-8.45) to 32.2 (26.7-37.8; p<0001). There was a clear step increase in website access from the date of iPad installation. Comparing the increases in average weekly views for those pages with direct link iPad icons (Clinical 11.4 before, 16.6 after, 46%, Schedule 30, 39, 30%, Calendar 10.7, 46.3, 330%, Home 84.1, 115.4, 37%) to the top accessed pages without iPad icons (Research 4.3, 6.2, 44%, Ultrasound 4.9, 9.8, 100%) did not, other than for the calendar page, demonstrate an observable difference. However, when analysed by views originating the hospital IP address, the pages with iPad icons were responsible for 88% of landing pages. Over the last two years the department iPads were responsible for 17% of our page views, with 6 of the department guideline pages featuring in the top 20 pages viewed. Conclusion: Provision of preconfigured iPad devices within the clinical environment of a busy ED significantly increases access from within that environment to a department website.

Introduction: Dental complaints and emergencies are a common emergency department (ED) issue that has not been extensively studied. This study aimed to provide an evaluation of Canadian practice patterns and clinical training relating to dental emergencies in the ED. Methods: We conducted an electronic survey inviting 1520 Canadian emergency medicine (EM) physicians from CAEP’s physician distribution network. Thirty-three questions were asked regarding ED physician training with dental emergencies, practice patterns and comfort with dental care, current available ED dental resources, and how dental care may be improved in Canadian EDs. Standard descriptive statistics were calculated. Results: Survey response rate was 15.1%. Respondents were predominantly male (62.8%) with a mean 15.3 years (SD: ±9.8) of practice, and were primarily CCFP-EM (50.7%) or FRCP-trained (25.6%) in either tertiary (48.0%) or community (36.3%) teaching hospitals. They received broad training on dental issues, but this was limited in scope to ≤1 day of residency (61.4%). A combined majority (59.6%) felt their residency left them somewhat to very unprepared for treating dental complaints, and <40% of physicians reported feeling comfortable with specific, common dental emergency procedures, with the exception of avulsed tooth storage (61.1%). For pain management and local trauma exploration, 36.9% felt somewhat to very uncomfortable performing oral and facial nerve blocks. Many respondents do not have access to any dental emergency supplies (48.0%), or do not know if they have any access (14.2%). Furthermore, 18.9% have no access to any professional support for help with dental emergencies requiring advanced management. Respondents believe dental emergency consultant support is an issue at their centre (62.5%). EM physicians want more training with dental emergencies (79.5%) and improved access to dental-specific emergency materials in their departments (63.7%). The greatest barriers to providing good ED dental care were cost to patients (72.7%), physician comfort treating complaints (54.7%), and clear follow-up with outpatient dental professionals (54.3%). Conclusion: ED physicians feel relatively unprepared by their residency training to treat dental complaints, and professional dental support is an issue in the majority of EDs. Dental care may be improved with more access to training, to dental ED resources and professional support.

Introduction: Low back pain (LBP) is an extremely frequent emergency department (ED) presentation. Although LBP imaging often results in no change to the ED management, does not identify abnormalities, and has documented risks (e.g., radiation exposure), advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging [MRI]) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness and safety of interventions aimed at reducing imaging in the ED for LBP patients. Methods: Six bibliographic databases and grey literature were searched. Comparative studies assessing interventions aimed at reducing ED imaging for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility, completed data extraction, and assessed the quality of included studies. Due to a limited number of studies and significant heterogeneity, a descriptive analysis was performed. Results: The search yielded 510 unique citations of which three before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and post-intervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The interventions to reduce lumbar spine imaging varied considerably. Study interventions included: 1) clinical decision support (i.e., a specialized X-ray requisition form), which reported a 47.4% relative reduction of lumbar spine radiography referrals; 2) clinical decision guidelines, which reduced referrals by 43.8%; and 3) multidisciplinary protocols, which reported a reduction in the MRI referral rate by 26.1%. Despite reductions in simple imaging, CT use increased in two of the three studies. Conclusion: LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation). Yet, evidence of interventions’ effectiveness in reducing imaging for ED patients with LBP is sparse. While there is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED, unintended consequences have been reported and additional studies employing higher quality methods are strongly recommended.

Introduction: Cellulitis and erysipelas are common presentations for the general practitioner. Antibiotic therapy targeting beta-hemolytic streptococci and Staphylococcus aureus is the mainstay of treatment for children and adults with these infections. Although evidence-based Canadian guidelines for appropriate management exist, inconsistent practices persist. Our objective was to determine the level of adherence to current evidence by emergency physicians at two academic hospitals in Kingston, Ontario. Methods: We conducted a retrospective chart review of 200 randomly selected electronic medical records. Records belonged to patients with a discharge diagnosis of cellulitis or erysipelas who were seen in the emergency departments of Kingston General Hospital or Hotel Dieu Hospital between January 1 and June 30, 2015. We manually collected data describing patient demographics, medical history, and medical management. Results: There were 707 total visits to the emergency departments in the study period for cellulitis or erysipelas. In our random sample, for those diagnosed with cellulitis, 44% received oral cephalexin alone, which was the most common form of therapy for uncomplicated infection. Of all the patients who received any antibiotics, 36% received at least one dose of parenteral antibiotics, despite only 6.7% showing systemic signs of illness. Emergency physicians chose ceftriaxone for 88% of the patients who received parenteral antibiotics. Conclusion: There was wide variation in antibiotic selection and route of administration for patients with cellulitis or erysipelas. Ceftriaxone was chosen for most patients receiving parenteral antibiotics, but it may not have been the most effective antibiotic in some cases. Overuse of antibiotics is common, and we believe medication choice should be justified based on disease severity, spectrum of activity, and regional antibiotic resistance patterns, among other factors. In conclusion, we found that emergency physicians could more closely align management plans with current guidelines to improve management of uncomplicated infection and reduce unnecessary administration of parenteral antibiotics.

Introduction: Recent studies have shown that point of care ultrasound is a valuable tool in the assessment and management of shock in the Emergency Department (ED). Despite proven utility, data is limited on the current utilization and quality assurance of POCUS in ED management of shock. The aim of this study was to determine the rate of POCUS use, characterize data collection methods and determine rate of quality assurance in both the ED and Intensive Care Unit (ICU) of a tertiary care academic center. Methods: The study included all patients who visited the ED from Jan-Jun 2015 that were transferred to the ICU, and were in shock, as determined by sBP <90, diagnostic code or vasopressor use. Patient charts, as well as wirelessly archived ultrasound studies were reviewed to determine which patients had POCUS performed, and how the results were recorded. By reviewing formal worksheets archived online, it could be determined if a management change was recommended, if studies were over-read for quality assurance and if improvement was recommended to image acquisition or interpretation. Results: Both departments used POCUS in roughly half of patients presenting in shock (53% ED, 41% ICU) with no statistical difference in usage (Δ12, 95% CI −0.01 to 0.25; p=0.06). Most ED studies (87%), had some form of documentation either on paper or online, however few (9%) had a formal worksheet completed. In comparison 71% of ICU studies had a worksheet. There was no difference in the number of performed scans that were saved electronically (66% ED vs 71% ICU; Δ5%, 95%CI −0.13 to 0.21; p=0.60).In the ICU the majority (77%) of the formal reports recommended a management change as a direct result of scan findings. Furthermore, of worksheets submitted for quality assurance (88%), over half the reviews (55%) suggested an improvement in image acquisition or interpretation. Conclusion: To our knowledge, our study is the first to demonstrate that POCUS is only utilized in about half of the shock cases in ED and ICU. Given that the majority of the formally reported studies in the ICU that were over-read for quality assurance found areas for potential improvement and given that the majority of ED studies were reported informally, it stands to reason that POCUS operators in the ED could benefit from a formalized quality assurance program. Future studies should explore potential barriers to implementation of such a program.

Introduction: Point of care ultrasound (US) is a key adjunct in the management of trauma patients, in the form of the extended focused assessment with sonography in trauma (E-FAST) scan. This study assessed the impact of adding an edus2 ultrasound simulator on the diagnostic capabilities of resident and attending physicians participating in simulated trauma scenarios. Methods: 12 residents and 20 attending physicians participated in 114 trauma simulations utilizing a Laerdal 3G mannequin. Participants generated a ranked differential diagnosis list after a standard assessment, and again after completing a simulated US scan for each scenario. We compared reports to determine if US improved diagnostic performance over a physical exam alone. Standard statistical tests (χ2 and Student t tests) were performed. The research team was independent of the edus2 designers. Results: Primary diagnosis improved significantly from 53 (46%) to 97 (85%) correct diagnoses with the addition of simulated US (χ2=37.7, 1df; p=<0.0001). Of the 61 scenarios where an incorrect top ranked diagnosis was given, 51 (84%) improved following US. Participants were assigned a score from 1 to 5 based on where the correct diagnosis was ranked, with a 5 indicating a correct primary diagnosis. Median scores significantly increased from 3.8 (IQR 3, 4.9) to 5 (IQR 4.7, 5; W=219, p<0.0001).Participants were significantly more confident in their diagnoses after using the US simulator, as shown by the increase in their mean confidence in the correct diagnosis from 53.1% (SD 22.8) to 83.5% (SD 19.1; t=9.0; p<0.0001)Additionally, participants significantly narrowed their differential diagnosis lists from an initial medium count of 3.5 (IQR 2.9, 4.4) possible diagnoses to 2.4 (IQR 1.9, 3; W=-378, p<0.0001) following US. The performance of residents was compared to that of attending physicians for each of the above analyses. No differences in performance were detected. Conclusion: This study showed that the addition of ultrasound to simulated trauma scenarios improved the diagnostic capabilities of resident and attending physicians. Specifically, participants improved in diagnostic accuracy, diagnostic confidence, and diagnostic precision. Additionally, we have shown that the edus2 simulator can be integrated into high fidelity simulation in a way that improves diagnostic performance.

Introduction: Predatory publishing is a poorly studied emerging threat to scientists. Junior researchers are preferred targets as they are under academic pressure to publish but face high rejection rates by many medical journals. Methods: All electronic invitations received from predatory publishers and fraudulent conferences were collected over a 6-month period (28th April to 27th October 2016) following the first publication of a junior researcher as a corresponding author. Beall’s list was used to identify predatory publishers and James McCrostie’s criteria to assess if a conference should be considered as predatory. The content of electronic invitations was analyzed and is presented with descriptive statistics. Results: A total of 162 electronic invitations were received during the study period. Seventy-nine were invitations to submit a manuscript. Few invitations disclosed information related to publication fees (9, 11.4%) or mentioned any publication guidelines (21, 26.6%). Most invitations reported accepting all types of manuscripts (73, 92.4%) or emphasized on a deadline to submit (62, 78.4%). These invitations came from 22 different publishers lead by OMICS with 27 invitations (34.2%). Seventy-two invitations to be a speaker (55, 73.4%) or attend (17, 23.6%) a predatory conference were received. These conferences were held most frequently in the USA (25, 34.7%), United Kingdom (15, 20.8%) or United Arab Emirates (8, 11.1%) with only eight mentioning registration fees (11.1%). Forty-one conferences (57.0%) were unrelated to the author’s affiliations or research interests. Finally, five invitations to be a journal’s guest editor, five invitations to become a member of a journal editorial board and one invitation to contribute to the creation of a new journal were received. Conclusion: Young researchers are frequently exposed to predatory publishers and fraudulent conferences. An electronic invitation was received almost daily following the first publication as a corresponding author. Academic institutions worldwide need to acknowledge and educate young researchers of this emerging problem.

Introduction: Medical transport services are essential in the regionalization of trauma care. Given the limited number of designated trauma centers, transport times can be prolonged, with patient care managed by paramedics for the duration of their transfer. Pain management is a paramount component, but oligoanalgesia can occur. The primary objective of this study was to evaluate pain management practices during transport of trauma patients by air. Methods: We conducted a 12-month review of ORNGE electronic paramedic records. ORNGE is the exclusive provider of air and land transport in Ontario, Canada. Cases from 1 January 2015 to 31 December 2015 were screened. Patients were identified according to inclusion (≥18 years old requiring transportation to designated trauma center) and exclusion criteria (GCS<14; intubation; accompanied by a nurse or physician). Information was collected in a standardized, piloted data form used by a single trained data extractor. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment according to changes on a 10-point numeric rating scale (NRS), patterns of analgesia administration, and analgesia-related adverse events (AEs). Results were reported as mean, (standard deviation), [range], or percentage. Results: Of 600 potential records, 372 patients met our inclusion criteria with the following characteristics: age 47.0 [19-92] years; 70.4% male; 97.0% blunt injury. Duration of transport was 82.4 (46.3) minutes. Pain was initially assessed in 90.0% of patients. Overall, NRS at baseline was 4.9 (2.8). Of the 62.4% who received analgesia, NRS at baseline was 5.9 (2.5). Fentanyl was most commonly administered (78.5%) at 44.3 [25-60] mcg. NRS after the first dose of analgesia decreased by 1.1 (1.6) points. A total of 73.7% of patients received further analgesia, equal to 2.4 [1-19] additional doses. While 23.4% of patients had no change in NRS after the first dose of analgesia, subsequent doses resulted in no change in NRS in over 65% [65.4-71.3] of patients. A total of 43 AEs (6.7%) were recorded after 638 doses of analgesia, and the most common AE was nausea (39.5%). Conclusion: The majority of patients were assessed for pain. Although the first analgesia administration had minimal effect on NRS, subsequent doses appeared to have even less of an impact. AEs were infrequent.