Introduction: ED and hospital overcrowding cause offload delays that remove EMS crews from service and compromise care delivery to patients. Prolonged ED boarding times are associated with increased hospital LOS and patient mortality, but the impact of offload delays has not been studied. Our objective was to determine whether offload delays are associated with adverse system and patient outcomes. Methods: From July 2013 to June 2016, administrative data was collated from four Calgary adult EDs. All CTAS 2 and 3 EMS arrivals were studied. Those assigned an ED care space within 15 minutes were considered controls while those with delays of ≥60-minutes were considered ‘delayed’. Multivariable logistic regression was used to determine propensity scores, which were used to match delayed patients to nearest neighbor controls. Matching variables for propensity modeling included age, sex, CTAS level, ED site, arrival day and time, living situation (homecare/facility vs. independent), complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other) and previous ED use (visits within 1 year). The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality. Results: A total of 111,743 patients were studied: 70711 controls and 41032 delayed (median time to stretcher of 8 vs. 109 minutes). There was significant baseline covariate imbalance: Delayed patients were more likely to be female, older, have lower CTAS acuity, arrive on weekdays and evenings, to have general medical complaints, and to arrive at the slowest offload site. In the unmatched analysis, delayed patients had lower 7-day mortality (2.1% vs. 2.6%), similar 30-day mortality (3.5% vs. 3.6%), and longer hospital LOS (10.3 vs. 9.8 days). In the propensity-matched analysis (41016 patients per group), covariate balance was substantially improved and outcomes differed slightly. Seven and 30-day mortality were essentially unchanged, but between group differences for hospital LOS disappeared (10.3 vs. 10.2 days). Conclusion: Propensity analysis suggests that EMS patients exposed to offload delays have similar 30-day mortality and slightly lower 7-day mortality than patients who receive timely ED access. While offload delays lead to substandard hallway care, patient dissatisfaction, and remove EMS crews from service, the levels of offload delay studied here were not associated with higher mortality or prolonged hospital LOS.

Introduction: Paramedics in our region do not perform 15-lead ECGs. As a result, patients experiencing a Right Ventricular Infarct (RVI) may receive nitroglycerin (NTG). In many cases, paramedics do not administer NTG to those with inferior STEMI out of concern that there may be an associated RVI. The purpose of this study is to determine if there is a difference in prehospital adverse events (AEs) associated with NTG administration in patients with unrecognized RVIs compared to those with an inferior STEMI and no RVI. Methods: Ambulance Call Records (ACR) of patients with prehospital STEMI between Jan 1, 2012 and Dec 31, 2015 were analyzed for the incidence of NTG administration. AEs were defined as HR<60 bpm, systolic BP <100 mmHg or drop of 1/3, GCS decrease of >2, syncope, arrest or death. Hospital records were reviewed to determine patients diagnosed with an inferior STEMI without RVI and those with a concurrent or primary RVI as diagnosed on angiography, ECG or discharge diagnosis. Results: Of the 334 ACRs that were filtered and manually reviewed, 144 were excluded (not STEMI, inter-facility transports, duplicate ACR) resulting in 189 patients that had a prehospital STEMI. The mean (SD) age was 66.9 (13.5) years and 70.6% were male. Of 189 STEMI patients, 82 (42.9%) received NTG. Nineteen (41.3%) of these patients were subsequently diagnosed with RVI and 27 (58.7%) had inferior STEMI without RVI. For patients receiving NTG, AEs occurred in 11 (57.9%) within the RVI group, and 10 (37.0%) within the inferior STEMI group (Δ 20.9%, 95% CI -7.8% to 45.4%, p=0.2). Cardiac arrest or death did not occur in either group. A total of 107 did not receive NTG and of these, 93 (86.9%) did not meet conditions or had contraindications for NTG use (22 RVI, 42 inferior STEMI). Three patients had a cardiac arrest and one died while in EMS care, none of which received NTG or had RVIs. Conclusion: Results of this study suggest no difference in the rate of AEs between patients with inferior STEMI and STEMI with RVI when NTG is administered in the prehospital setting. In our EMS system, the conditions and contraindications of NTG administration may be protective against AEs in RVIs, so the potential benefit of a prehospital 15-lead ECG may be limited.

Introduction: Arriving EMS patients often experience offload delay due to a lack of available care spaces. Arrival in an overcrowded ED is the primary cause of offload delay, but patient characteristics may also play a role. Our objective was to describe system and patient level determinants of offload delay. Methods: From July 2013 to June 2016, administrative data was collated from the four Calgary Zone adult EDs. All CTAS level 2 and 3 patients arriving by ambulance were eligible for study. To define patient complexity and illness severity, we captured patient demographic data, living situation (homecare/facility vs. independent), vital signs, complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other), biochemical parameters (serum Na, K, creatinine, hemoglobin, WBC), patient care needs (IV fluid bolus, IV antibiotics, CT scan, admission) and mortality at 7 and 30 days. Results: 162,002 EMS patients were studied. Of these, 67,785 went to a care space within 15 minutes (minimal offload delay), 53,185 between 15 and 59 minutes (moderate offload delay), and 41,032 at ≥60 minutes (severe offload delay). Vital signs, biochemical and hematologic parameters did not differ between groups. ED site was a strong predictor of offload delay (odds ratio {OR}=1.0, 2.03, 2.14, 3.5 for the 4 EDs), as was arrival on weekday (OR=1.38) or night shift (OR=0.71). After adjusting for site, day and time of arrival, multivariate logistic regression models showed the following associations with offload delays of more than 15 minutes: male sex (OR=0.94), age (OR=1.01 per year of age), dependent living situation (OR=1.15), CTAS 3 acuity (OR=1.27), number of prior ED visits within a year (OR=1.06 per visit), and complaint category: general medical (1.0), cardiovascular (0.90), mental health/neuro (0.90), GI (0.85), trauma/MS (0.61). Odds ratio estimates were precise—all with p<0.001. Offload delay was associated with prolonged time to MD, increased EDLOS and higher LWBS/AMA rates. Delayed patients had similar rates of IV antibiotic use, but lower rates of IV fluid bolus, CT use, admission, and 7-day mortality. Conclusion: The strongest predictor of offload delay is arrival to a crowded ED, but patient factors including female sex, older age, dependent living status and repeat hospital use increase risk. Patients subjected to offload delay also appear to have lesser immediate care needs and lower short-term mortality.

Introduction: The Community Referral by Emergency Medical Services (CREMS) program was implemented in January 2015 in Southwestern Ontario. The program allows Paramedics, who are interacting with a patient as a direct result of a call to 9-1-1, to directly refer patients in need of home care support to their local Community Care Access Centre (CCAC) for needs assessment. If indicated, subsequent referrals are made to specific services (e.g. nursing, physiotherapy and geriatrics) by the CCAC. Ideally, CREMS connects each patient with appropriate, timely care, supporting individual needs. Similar referral programs have been implemented in communities with preliminary data showing positive results. The primary objective of this project was to evaluate the success of the CREMS program by determining the number of referrals made by EMS in London-Middlesex to CCAC since implementation as well as the proportion of referred patients receiving a new or increase in service due to EMS referral. Methods: Data for all CCAC referrals from London-Middlesex EMS was collected for a thirteen month period (February 2015-February 2016). Data was evaluated for quantity of referrals and proportion that led to a patient receiving new or increased home care service. Results: There were 436 referrals made in the study period which represented 391 individuals. 54% of patients were between 65-84 years of age. Of the 391 patients, 162 (41%) were not known to CCAC and of those 119 (73%) received a new service due to EMS referral. The most common new services were occupational therapy (61%) and nursing (47%). Of the 229 (59%) of patients that were already known to CCAC, 101 (44%) received an increase in service due to EMS referral. No patients refused a new or increase in service. Conclusion: Of all patients referred to CCAC, 56% received a new service or had a change in existing services which suggests that a large number of patients benefited from early EMS referral to community services. The results of this project provide impetus to continue and expand the CREMS program. Future studies will evaluate if the implementation of this program has reduced patient reliance on 911 requests for paramedic care as well as Emergency Department transports.

Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically between 8 and 12%. We sought to report the trends in survival in British Columbia (BC) over a 10-year period. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2006 to 2016 within BC’s four metropolitan areas. We included EMS-treated adult patients without DNR orders. To describe baseline characteristics we organized patient characteristics in three time periods: 2006-09, 2010-13, and 2014-16 (first and last periods reported below). The primary and secondary endpoints were survival at hospital discharge and return of spontaneous circulation (ROSC). We tested the significance of year-by-year trends in baseline characteristics, and performed multivariable Poisson regression, using calendar year as an independent variable, to calculate risk-adjusted rates for survival. Results: Between January 1, 2006 and March 31, 2016 there were a total of 26 433 non-traumatic OHCAs, with 15 145 included in this study. There were significant decreases in the proportion with initial shockable cardiac rhythms (28% to 23%) and bystander witnessed arrests (42% to 39%), however significant increases in the proportion with bystander CPR (40% to 49%) and ALS treatment (86% to 97%), and the median chest compression fraction (0.81 to 0.87). There was a significant increase in the median time until termination of resuscitation in those who did not achieve ROSC (27 to 32 minutes), and a significant decrease in the proportion of patients who were transported in absence of ROSC (17% to 6.5%). There was a significant improvement in achieving ROSC (44% to 48%; adjusted rate ratio per year 1.02, 95% CI 1.01 to 1.02) and survival at hospital discharge (10% to 14%; adjusted rate ratio per year 1.05, 95% CI 1.04 to 1.06). Both subgroups of initial shockable (adjusted rate ratio per year 1.04, 95% CI 1.03 to 1.05) and non-shockable (adjusted rate ratio per year 1.08, 95% CI 1.06 to 1.12) cardiac rhythms demonstrated survival improvement. Conclusion: Despite a significant decrease in those with initial shockable rhythms, out-of-hospital cardiac arrest survival in BC’s metropolitan regions increased by approximately 40% over a 10-year period. During this time there were system changes and quality of care improvements as provided by bystanders and professionals.

Introduction: ST-segment elevation myocardial infarction (STEMI) remains a significant cause of morbidity and mortality in North America, with recent studies suggesting that between 4 to 11% of patients diagnosed with STEMI suffer an out-of-hospital-cardiac arrest (OHCA). Previously published research has shown that shorter time to initial defibrillation in patients with VF/VT OHCA increases functional survival. The purpose of this study is to assess whether the routine application of defibrillation pads in STEMI decreases the time to initial defibrillation in those who suffer OHCA. Methods: Ambulance call records (ACR) for patients diagnosed with STEMI in Middlesex-London in the prehospital setting from Jan 1, 2012 to Jun 30, 2016 were reviewed. Patients were included in the study if they were 18 years of age or older with a confirmed diagnosis of STEMI and suffered an OHCA with an initial shockable rhythm (VF or VT) while in paramedic care. The pre-pad protocol (routine application of defibrillation pads in STEMI patients) was implemented by Middlesex-London EMS in July 2014. If inclusion criteria were met, ACRs were reviewed to determine whether the pre-pad protocol was implemented and to extract the time to initial defibrillation and relevant demographic and event features. Associated hospital charts were reviewed to evaluate inpatient event features and survival. T-test was used to assess the difference between mean times to defibrillation. Results: 446 patients were diagnosed with prehospital STEMI. Of those, 11 patients experienced a paramedic witnessed cardiac arrest. Four of the 11 had defibrillation pads applied upon diagnosis of STEMI. In patients who received pre-pad application, the mean time to initial defibrillation was 17.71 sec, compared to 72.71 sec in patients who had pads applied following arrest (MD 54.97 sec CI 22.69 to 87.24 sec). All patients treated with the pre-pad protocol survived to discharge from hospital, while one patient in the routine care group died in the ED. Conclusion: Routine application of defibrillation pads decreases the time to initial defibrillation in STEMI patients who suffer OHCA. Larger studies are required to evaluate whether this decreased time to defibrillation translates into mortality benefit in this subset of patients who experience OHCA.

Introduction: Conventional wisdom states that hypoglycemia is a frequent peri-seizure phenomenon and must be tested for. Conventional wisdom also lists hypoglycemia as a cause of seizures. Recent literature disputes this. Paramedic medical directives continue to direct paramedics to determine the blood sugar level on all seizure patients. The purpose of this study was to determine the frequency of hypoglycemia in patients identified as having “seizure” as the primary or final problem code in Ambulance Call Reports (ACRs) from a large regional paramedic base hospital program. Methods: We conducted a retrospective analysis of iMedic platform, electronic ACRs, for a 2 year period (Jan 01, 2014 to Dec 31, 2015), from 8 Paramedic Services serving a rural and urban population of 1.4 million. 5854 calls, had “seizure” listed as a primary or final problem code. A 10% sample was generated using a random number table. ACRs were manually searched, data abstracted onto spread sheets, and the results analyzed using descriptive statistics (Wizard ver 1.8.16 for Mac). Results: 582 calls were analyzed. 430 (73.9%) were adults and 152 (26.1%) were paediatric (age <18). A blood sugar was determined in 501/582 (86.1%) of all calls; adults 388/430 (90.2%), peadiatric 113/152 (74.3%). The Glasgow Coma Score, when measured, was 15 in 280/575 (48.7%) cases. Seizures were witnessed by paramedics in 47/582 (8.1%) calls; adults 33/430 (7.7%), paediatric 14/152 (9.2%). In calls were paramedics witnessed a seizure a blood sugar was determined 36/47 (76.6%) of the time; adults 25/33 (75.8%), paediatric 11/14 (78.6%). Hypoglycemia (BS<4.0 mmol/L in an adult and 3.0 mmol/L in child<age 2 ) was found in 1 case when BS was checked-overall 1/501 (0.2%); adults 1/388 (0.3%), paedatric 0/113 (0.0%). Case 1-age 70 yr, GCS 12, BS 3.8 mmol/L. Conclusion: Hypoglycemia was rarely found in patients who had a pre-hospital seizure. It did not require treatment. When it was found, hypoglycemia was unlikely to be the cause of the seizure. The results are similar to the findings from other recent, retrospective, reviews. The routine determination of blood sugars in all patients who have had a seizure prior to paramedic arrival should be reconsidered.

Introduction: Active substance use and unstable housing are both associated with increased emergency department (ED) utilization. This study examined ED health care costs among a cohort of substance using and/or homeless adults following an index ED visit, relative to a control ED population. Methods: Consecutive patients presenting to an inner-city ED between August 2010 and November 2011 who reported unstable housing and/or who had a chief presenting complaint related to acute or chronic substance use were evaluated. Controls were enrolled in a 1:4 ratio. Participants’ health care utilization was tracked via electronic medical record for six months after the index ED visit. Costing data across all EDs in the region was obtained from Alberta Health Services and calculated to include physician billing and the cost of an ED visit excluding investigations. The cost impact of ED utilization was estimated by multiplying the derived ED cost per visit by the median number of visits with interquartile ranges (IQR) for each group during follow up. Proportions were compared using non-parametric tests. Results: From 4679 patients screened, 209 patients were enrolled (41 controls, 46 substance using, 91 unstably housed, 31 both unstably housed and substance using (UHS)). Median costs (IQR) per group over the six-month period were $0 ($0-$345.42) for control, $345.42 ($0-$1139.89) for substance using, $345.42 ($0-$1381.68) for unstably housed and $1381.68 ($690.84-$4248.67) for unstably housed and substance using patients (p<0.05). Conclusion: The intensity of excess ED costs was greatest in patients who were both unstably housed and presenting with a chief complaint related to substance use. This group had a significantly larger impact on health care expenditure relative to ED users who were not unstably housed or who presented with a substance use related complaint. Further research into how care or connection to community resources in the ED can reduce these costs is warranted.

Introduction/Innovation Concept: Background: Competency based medical education (CBME) is a method of assessing resident performance through standardized tasks and milestones. The Royal College of Physicians and Surgeons of Canada has started phasing in CBME as the preferred training method, but no tool support exists to process this data. Approximately 400 data points are collected per resident per year at McMaster’s Division of Emergency Medicine. This is an unwieldy amount of data to analyze. Objective: Recognizing that collection and analysis of resident data is an important facet to postgraduate medical education, McMaster University began developing a program to provide predictive automated data analysis of resident performance. Methods: To achieve the stated objective, we adapted a design thinking methodology, which emphasizes the importance of human-centered design. By interviewing stakeholders, we collected user requirements and “pain points” that allowed us to build and evaluate multiple prototypes addressing their problems, such as the ability to process data into reports, real-time reporting, and predictive analytics. We solicited feedback from our stakeholders to iteratively refine the prototypes, ensuring that it was user intuitive and met user needs. Curriculum, Tool, or Material: We developed a software platform that collects, aggregates, reports, and has the possibility of analyzing resident data in real time. It also can present performance data via a real-time dashboard. Having automated the report generating process, administrative workload is reduced to a monitoring capacity. Quantitative data on resident performance has been analysed using artificial Neural Network to identify patterns in resident performance. It performs with a sensitivity of 81% and a specificity of 43%, and accurately predict which residents require remedial support 43% of the time. When built into a learning management system, this allows for the provision of additional support to residents-at-risk. Conclusion: Combining machine learning with resident assessment data has allowed us to build a promising predictive model to predict resident outcomes. This gives us the potential to decrease administrative workload and improve data quality by providing real-time performance dashboards and eliminating the redundancies of manual data processing. If scaled, this innovation might assist program directors in determining competency of residents and human resource planning for the healthcare systems at large.

Introduction/Innovation Concept: Quality Improvement (QI) remains a challenge and has been identified as a key competency by the Royal College of Physicians and Surgeons. Hospitals can be dehumanized environments, both for patients and the staff working there. The distant understandings of each other’s expectations during their health care encounter often create a sense of futility, frustration, and moral distress in therapeutic relationships. The transient nature of interactions and workplace culture in emergency departments (ED) enhances this distress. Methods: Working in a cross-disciplinary fashion, we explored how residents could develop quality improvement initiatives as a way to engage personal interests for QI measures. Key goals for developing these tools were 1) Learn cross-disciplinary tools for observation, inquiry, and improvement, 2) Develop reflective practice for residents, and 3) create ownership for the work and ongoing areas for improvement in local EDs for learners. Curriculum, Tool, or Material: We developed a process that would connect designers, residents, and content experts to an area of QI. Residents will be asked to identify an area in the ED that they field would benefit from a QI project (examples include: trauma team activation, waiting room anxiety, and referral delays from the ED). Working with designers and stakeholders (including patient representatives), learners would map the experience of a particular project. Strengths and opportunities for improvements would be identified at each step of the project. The team would then prototype solutions which will be presented to site chiefs for implementation and evaluation. Conclusion: Working with designers offers a practical and powerful approach to undertaking QI projects in the ED. We hope that this process allows residents to undertake projects that they are personally invested in and helps build longitudinal relationships beyond direct clinical work with the local ED they are working in

Introduction/Innovation Concept: Emergency Medicine (EM) is a specialty that requires physicians to deal with acutely ill patients in a fast-paced environment, which can create stress, mental exhaustion and burnout. Continually changing working teams in the Emergency Department does not always allow appropriate debriefing for difficult patient encounters and outcomes on shift. To address these challenges, we sought to adapt and implement a peer-support rounds called ‘Ice Cream Rounds’ used in some Pediatric training programs for an EM training program. Methods: CCFP and Royal College EM residents were surveyed to determine interest and need for Ice Cream Rounds. Of the 31/50 respondents, 87% (26/31) identified their co-residents as their main source of support after difficult patient encounters and 71% (22/31) felt that current opportunities to debrief after difficult experiences were only “sometimes” or “rarely” adequate. Overall, 84% (26/31) were interested in attending Ice Cream Rounds. Residents expressed that they did not want staff present for Ice Cream Rounds so two residents (SCS and TK) obtained training to lead peer-support sessions from The Faculty of Medicine Wellness Program. Attendance at rounds was voluntary and the EM program provided funding for refreshments. Two Ice Cream Rounds were piloted. Attendance and feedback was recorded from pilot sessions. Curriculum, Tool, or Material: Resident-only, peer-run confidential debriefing sessions. Sessions were voluntary and lasted one hour. Approximately 20-30/50 residents attended each Ice Cream Rounds. Discussions were confidential but include topics such as difficult patient encounters, poor patient outcomes, challenges in residency, and ethical issues. In response to positive attendance and feedback, the EM program provided 3-4 one-hour protected time slots with a stipend for refreshments for future academic years. Comments from residents consistently reaffirmed that Ice Cream Rounds was a helpful forum to discuss important issues with colleagues and provided a safe and confidential resource to help cope with residency challenges. Conclusion: We adapted, implemented, and evaluated a novel Peer-Support Wellness Rounds for debriefing resident issues and difficult patient encounters in a EM training program. To our knowledge this is the first Canadian initiative to implement such rounds in an EM training program. We believe that this template can be easily adopted by any EM training program and will effectively address wellness challenges faced by residents during their training.

Introduction: Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a minimal evidence for any outcome benefit. We completed an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We report diagnostic impact and mortality elsewhere. Methods: The SHoC-ED1 study compared the addition of PoCUS to standard care within the first hour in the treatment of adult patients presenting with undifferentiated hypotension (SBP<100 mmHg or a Shock Index >1.0) with a control group that did not receive PoCUS. Scans were performed by PoCUS-trained physicians. 4 North American, and 3 South African sites participated in the study. Resuscitation outcomes analyzed included volume of fluid administered in the ED, changes in shock index (SI), modified early warning score (MEWS), venous acid-base balance, and lactate, at one and four hours. Comparisons utilized a T-test as well as stratified binomial log-regression to assess for any significant improvement in resuscitation amount the outcomes. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no significant difference in mean total volume of fluid received between the control (1658 ml; 95%CI 1365-1950) and PoCUS groups (1609 ml; 1385-1832; p=0.79). Significant improvements were seen in SI, MEWS, lactate and bicarbonate with resuscitation in both the PoCUS and control groups, however there was no difference between groups. Conclusion: SHOC-ED1 is the first RCT to compare PoCUS to standard of care in hypotensive ED patients. No significant difference in fluid used, or markers of resuscitation was found when comparing the use of a PoCUS protocol to that of standard of care in the resuscitation of patients with undifferentiated hypotension.

Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.

Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP<100 or shock index>1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.

Introduction: Acute pharyngitis is a common reason for primary care or emergency department visits, often resulting in antibiotic prescription. Rapid antigen detection tests (RADT) are routinely used to diagnose Group A Streptococcus (GAS) pharyngitis. However, due to its low sensitivity, patient pressures and conflicting guidelines, the RADT often complicates management decisions. Our aim was to assess the impact of RADT in patients presenting with acute GAS pharyngitis on the antibiotic prescription rate and appropriateness of antibiotic management. Methods: We systematically searched Medline, Embase, and Cochrane databases from 1980 to June 2016. Studies were selected according to a predefined PRISMA protocol and data extracted by two independent reviewers. Prospective and retrospective studies that evaluated the impact of RADT on antibiotic prescription for pharyngitis were included. Study quality was assessed using Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale. Our main outcome was a dichotomous measure of antibiotic prescription, with or without RADT availability. Studies were combined if there was low clinical and statistical heterogeneity (I2<30%). Bivariate Mantel-Haenszel random effects model was used to perform meta analyses using SPSS 22 and Revman 5. Results: We identified 4003 studies: 139 were selected for full text review; 10 met our inclusion criteria (N=10859 participants, median age 31 years, 56.7% female). Mean antibiotic prescription rate in the RADT and control arm was 38.2% (SD 15.6) and 55.9% (SD 16.3), respectively. The use of RADT was associated with lower antibiotic prescription rate in both adults (OR=0.60 [95% CI 0.45-0.80], I2=8%, N=1407) and pediatrics (OR=0.49 [95% CI 0.44-0.55], I2=5%, N=976). There was no overall difference (p<0.3) in antibiotic prescription rate among disease severity (Centor scores 1-4). The use of RADT did not significantly impact the appropriateness of antibiotic management (OR=1.15 95% CI 0.94-1.5). Conclusion: The use of RADT is associated with a reduction in antibiotic prescription for patients with GAS pharyngitis without an increase in appropriate antibiotic use. Despite low prevalence of the disease in the population, antibiotic prescription rates are still high. These findings suggest great potential for antibiotic stewardship and reevaluation of current guidelines for managing GAS pharyngitis.

Introduction: Sepsis protocols call for the acquisition of blood cultures in septic emergency department (ED) patients.However, the criteria for blood cultures are vague, they are costly, only positive 8-12% of the time, with up to half of these being false positives. The objective of this study was to establish if positive blood cultures could be excluded in low-risk sepsis patients with levels of CRP below 20 ml/L. Methods: This was a multicenter prospective cohort study of 765 ED patients at St Paul’s and Mount St Joseph’s hospitals in Vancouver with sepsis (2 or more SIRS criteria and infection) and none of: immuncompromised, injection drug use, indwelling vascular device or septic shock (SBP<90 mmhg). Consecutive patients with sepsis had CRP and blood cultures obtained at the same time.OUTCOMES. True positive blood cultures, false positive blood cultures, positive blood cultures that changed patient management. True and false positive blood cultures were based on Infectious Disease Society of America Guidelines, and change in management was defined as change in type or length of antibiotic therapy and was blindly adjudicated by a medical microbiologist. Results: 765 ED patients with sepsis met inclusion criteria. Mean age was 48.3 years and 57% were male. Blood cultures were positive in 99/765 (12.9%) subjects, of which 19 were false positive (19.2%). CRP was >20 mg/L in 595/765 (77.8%) of patients. Of 170 subjects with a CRP<20 mg/L, 3 had a positive blood culture (1.8%; 95% CI 0.1%- 5%). Management was not changed in any patient with a positive blood culture and CRP level<20 mg/L. Of 19 subjects with a false positive blood culture, CRP was <20 mg/L for 6 (31.6%). Conclusion: In this cohort of low-risk sepsis patients, based on a CRP of <20 mg/L, acquisition of blood cultures could be safely avoided in 22.2% of patients, at significant savings to the health care system.

Introduction: Nightshifts may represent a more challenging work environment due to staff fatigue. Our objective was to determine if an association exists between health outcomes for patients seen in Calgary Zone Emergency Department (ED) during nightshifts as compared to other time periods. Methods: Administrative data from a city-wide electronic health record was collected from four urban EDs on all discharged patients during a 2-year period: January 2015-December 2016. A total of 454,125 patient visits were included and patients with a scheduled return to the ED were excluded. Three primary outcomes were selected to assess the effects of night shifts on the quality of care received by patients in the ED at night; (i) unscheduled returns to the ED within 7 days resulting in admission, (ii) mortality within 48 hrs and, (iii) mortality within 7 days of being seen by a physician. Non-night shifts were defined as patients seen on day and evening or 700-2300. The data was analyzed using descriptive statistics and precision reported via 95% confidence intervals. Results: For the outcome of returns resulting in admission, a 2.6% rate was noted for patients seen at night compared to 2.3% during non-night; OR 1.15 (95% CI 1.09-1.21). Furthermore, patients seen at night had a 0.033% rate of death, while non-night patients had a 0.022% chance of death within 48 hrs of discharge; OR 1.53 (95% CI 0.98-2.38). For mortality within 7 days, the rate of death observed was 0.10% and 0.078% respectively; OR 1.24 (95% CI 0.97-1.60). Conclusion: Our study identified presenting to the ED at night as a potential risk factor for adverse patient outcomes using 3 primary quality of care indicators. An adjusted analysis is needed to account for potential confounding variables and effect modifiers and is underway.

Introduction: Highly frequent users (HFU) of the emergency department (ED) remain a poorly defined and complex population. This study describes patient and visit characteristics for HFU of the ED, and analyzes subgroups of patients with mental illness, substance abuse, and/or ≥30 yearly ED visits. Methods: We performed a health records review of 250 randomly selected adults with >99th percentile of ED visit frequency (≥7 visits) at a tertiary care academic hospital with two EDs in 2014. Two reviewers collected demographic variables (age, sex, and comorbidities) and visit data (ED diagnosis, ED length of stay (LOS), ED presentation time (daytime 0800-1559 h, evening 1600-2359 h, overnight 2400-0759 h), consultation services, and final disposition). Data were analyzed using descriptive and univariate analyses, student t and Mann Whitney U tests. Results: Of 897 eligible patients who experienced 9,376 ED visits we included 250 patients (2,670 visits) in our main analyses, and an additional 11 patients (494 visits) outside of the random selection with ≥30 ED visits. Mean age was 53.4±1.3 (SEM), and 55.6% were female. Most patients had a fixed address (88.9%), and a family physician (87.2%). Top comorbidities included gastrointestinal (61.6%), cardiovascular (52%), and chronic pain issues (47.2%). Top ED diagnoses included musculoskeletal pain (9.6%), abdominal pain (8.4%) and alcohol-related presentations (8.5%). Hospital admission was required for 15.6% of visits. From all possible visits (3164 visits), consultations for social workers, geriatric emergency medicine nurses, or Community Care Access Centres were made for 5.9% of visits, with 47.3% of these patients presenting during daytime hours. Among visits requiring these consultations, median ED LOS was greatest in the evening (12.7 hours, range 1.4-45.2 hours), compared to daytime (5.4, 1.2-33.6; p=0.0002) or overnight (7.9, 1.0-38.3, p=0.02). Inter-rater review of 4.5% of abstracted health records revealed a kappa score of 0.8. Conclusion: This study highlights that a remarkably low proportion of HFUs received allied health consultations at the study sites, likely corresponding to a lack of available consultants outside of daytime work hours. Our findings suggest the need to address significant gaps in order to balance the clinical needs of patients who frequent the ED with currently available resources.

Introduction: Headaches are a common emergency department (ED) presentation. The objective of this study was to characterize headache presentations in Alberta over a five-year period and explore the proportion of patients with potentially severe pathology. Methods: Administrative health data for Alberta (years 2011-2015) were obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) headache presentations (ICD-10-CA: G43, G44, R51). Patients with a primary or secondary diagnosis code of headache were eligible for inclusion in the study. Exclusions were made using the following criteria: 1) sites without computed tomography (CT) scanners; 2) presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1; 3) patients with trauma or external mechanism of injury (e.g., ICD-10-CA codes S,T,V,W,X,Y); and 4) presentations receiving an enhanced/contrast CT (head). NACRS data were linked with a provincial diagnostic imaging data. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, 98,333 presentations were made by 66,970 patients (~0.3 presentations per patient per year; equivalent to one presentation every 3.4 years). Headache presentations increased from 15,643 in 2011 to 21,636 in 2015. The median age was 38 years (IQR: 29, 51 years); more patients were female (69.3%), had a CTAS score of 3 (55%) and arrived at the ED without ambulance (90.3%). The majority of patients had a primary ED diagnosis of headache (88%) and the most common co-diagnosis was benign hypertension (2.8%). Additional diagnoses indicating severe or pathological headaches, included: stroke (0.63%), subarachnoid hemorrhage (0.43%), infection (i.e., meningitis) (0.11%), and other brain hemorrhages (0.08%). Overall, the ED management of approximately 25% of presentations involved a head CT. Most patients were discharged from the ED (89.4%) after a median length of stay of 3.5 hours (IQR: 2.1, 5.2 hours). Conclusion: Headache-related ED presentations are increasing in Alberta, yet few severe/pathological diagnoses are being identified. Efforts to ensure appropriateness of head CT ordering could reduce exposure to ionizing radiation, improve patient flow and reduce health care costs; this imaging represents a target for future interventions.

Introduction: Medication discrepancies are unintended differences between a patient’s outpatient and inpatient medication regimens, and occur in up to 60% of hospital admissions. Canadian emergency departments (EDs) have implemented medication reconciliation forms that are pre-populated with outpatient medication dispensing data in order to reduce medication discrepancies and resultant adverse drug events. However, these forms may introduce errors of commission by prompting prescribers to reorder discontinued or potentially harmful medications. Our objective was to evaluate the incidence of medication discrepancies and errors of commission after the implementation of pre-populated medication reconciliation forms. Methods: This chart review included admitted patients who were enrolled in a parent study in which a research pharmacist prospectively collected best-possible medication histories (BPMHs) in the ED using all available information sources. Following discharge, research assistants uninvolved with the parent study compared medication orders documented within 48 h of admission with the BPMH to identify medication discrepancies and errors of commission. Errors of commission were defined as inappropriate continuations of medications and reordering discontinued medications. An independent panel adjudicated the clinical significance of the errors. We used regression methods to identify factors associated with errors. The sample size was limited by enrolment into the parent study. Results: Of 151 patients, 71 (47%; 95%CI 39.2-54.9) were exposed to 112 medication errors. Of these errors, 75.9% (85/112; 95%CI 67.1-82.9) were discrepancies, of which 18.8% (16/85; 95%CI 12.0-28.4) were clinically significant. Errors of commission made up 24.1% (27/112; 95%CI 17.3-32.8) of all errors, of which 37.0% (10/27; 95%CI 18.8-55.2) were clinically significant. Taking 8 or more medications was associated with a 5-fold greater odds of experiencing a medication error after controlling for confounders (OR 5.00; 95%CI 2.45-10.17; p<0.001). Conclusion: Clinically significant medication discrepancies and errors of commission remain common despite the implementation of electronically pre-populated medication reconciliation forms. Prospective studies are needed to evaluate whether using pre-populated medication reconciliation forms increases the risk of introducing errors of commission.