Introduction: Community Paramedics (CPs) require access to timely blood analysis in the field to guide treatment and transport decisions. Point of care testing (POCT), as opposed to traditional laboratory analysis, may offer a solution, but limited research exists on CP POCT. The objective of this study is to compare the validity of two POCT devices (Abbott i-STAT® and Alere epoc®) and their use by CPs in the community. Methods: In a CP programme responding to 6,000 annual patient care events, a split sample validation of POCT against traditional laboratory analysis for seven analytes (sodium, potassium, chloride, creatinine, hemoglobin, hematocrit, and glucose) was conducted on a consecutive sample of patients. The difference of proportion of discrepant results between POCT and laboratory was compared using a two sample proportion test. Usability was analysed by survey of CP experience, an expert heuristic evaluation of devices, a review of device-logged errors, coded observations of POCT use during quality control testing, and a linear mixed effects model of Systems Usability Scale (SUS) adjusted for CP clinical and POCT experience. Results: Of 1,649 CP calls for service screened for enrollment, 174 had a blood draw, with 108 patient care encounters (62.1%) enrolled from 73 participants. Participants had a mean age of 58.7 years (SD16.3); 49% were female. In 4 of 646 (0.6%) individual comparisons, POCT reported a critical value that the laboratory did not; with no statistically significant difference in the number of discrepant critical values reported with epoc® compared to i-STAT®. There were no instances of the laboratory reporting a critical value when POCT did not. In 88 of 1,046 (8.4%) individual comparisons, the a priori defined acceptable difference between POCT and the laboratory was exceeded; occurring more often in epoc® (10.7%;95%CI:8.1%,13.3%) compared to i-STAT® (6.1%;95%CI:4.1%,8.2%)(p=0.007). Eighteen of 19 CP surveys were returned, with 11/18 (61.1%) preferring i-STAT® over epoc®. The i-STAT® had a higher mean SUS score (higher usability) compared to the epoc® (84.0/100 vs. 59.6/100; p=0.011). Fewer field blood analysis device-logged errors occurred in i-STAT® (7.8%;95%CI:2.9%,12.7%) compared to epoc® (15.5%;95%CI:9.3%,21.7%) although not statistically significant (p=0.063). Conclusion: CP programs can expect valid results from POCT. Usability assessment suggests a preference for i-STAT.

Introduction: Our emergency department (ED) sees a low volume of high acuity pediatric cases. A needs assessment revealed that 68% of our Emergency Physicians (EP) manage pediatric patients in less than 25% of their shifts. The same percentage of EPs as well as ED nurses indicated they were uncomfortable managing a critically unwell neonate. Thus, an interprofessional curriculum focused on pediatric emergencies for ED staff was developed. In-situ simulation education was chosen as the most appropriate method to consolidate each didactic block of curriculum, and uncover important system gaps. Methods: Needs assessment conducted, and emerging themes informed IPE curriculum objectives. A committee of experts in simulation, pediatric emergencies and nursing education designed a full-day, RCPSC accredited, interprofessional in-situ simulation program. Results: Progressive segmental strategy maximized learning outcomes. The initial phase (2 hrs) comprised an” early recognition of sepsis” seminar and 4 rotating skills stations (equipment familiarity, sedating the child, IV starts, and mixing IV medication). This deliberate, adaptive, customized practice was enhanced by expert facilitation at each station, directly engaging participants and providing real-time feedback. The second phase allowed interprofessional teams of MDs, RNs and Physician Assistants to apply knowledge gained from the didactic and skills stations to in-situ simulated emergencies. Each group participated in two pediatric emergency scenarios. Scenarios ran 20 minutes, followed by a 40 minute debrief. Each scenario had a trained debriefer and content expert. The day concluded with a final debrief, attended by all participants. Formalized checklists assessed participants knowledge translation during simulation exercises. Participants assessed facilitators and evaluated the simulation day and curriculum via anonymous feedback forms. Debriefing sessions were scribed and knowledge gaps and system errors were recorded. Results were distributed to ED leaders and responsibilities assigned to key stakeholders to ensure accountability and improvement in system errors. Results All participants reported the experience to be relevant and helpful in their learning. All participants requested more frequent simulation days. System gaps identified included: use of metric vs imperial measurements, non-compatible laryngoscope equipment, inadequate identification of team personnel. As a result, the above-mentioned equipment has been replaced, and we are developing resuscitation room ID stickers for all team roles. Conclusion: Simulation as a culmination to a didactic curriculum provides a safe environment to translate acquired knowledge, increasing ED staff comfort and familiarity with rare pediatric cases. Additionally, is an excellent tool to reveal system gaps and allow us to fill these gaps to improve departmental functioning and safety.

Introduction: Mass Gathering Medicine (MGM) is a growing field within emergency medicine (EM) and providing care at electronic dance music events (EDMEs) is an increasingly popular activity with MGM groups. Often, health care students are allowed to participate. However, there is a lack of documented curricula to train junior learners in providing medical care at these events. To address this, we developed and initiated an interprofessional, simulation-based workshop for University of Alberta health care students interested in working at EDMEs. Methods: We used Kerns six-step approach to develop the workshops. Our MGM Interest Group identified a need for educational sessions in toxicology case management at EDMEs. A subsequent literature review revealed a paucity of pre-existing curricula on this topic for MGM learners. We created goals and objectives for the workshops, reflecting the knowledge, skills and attitudinal competencies required to provide appropriate medical care at these events. The workshops were implemented and evaluated in November 2016 and 2017. Results: A total of 44 medical and nursing students attended the workshops. An EM resident and staff physician, both with prior experience working at EDMEs, led each session. Each workshop began with a short didactic lecture followed by two hours of case-based training using two standardized patients and a high fidelity simulator. Topics were chosen based on previously published articles describing medical cases seen at EDMEs. The simulation replicated the actual space, noise and equipment available at the medical tents at these events. Two interprofessional learner groups took turns managing a different set of 3 patients: Set 1-opioid overdose (OD), alcohol/vomiting, sympathomimetic OD; Set 2-opioid OD not responsive to naloxone, anticholinergic/seizure, OD with hyperthermia. Initial assessment, medical management and team communication skills were emphasized. Debriefing was provided to learners immediately after each set of cases. After each workshop, the learners completed evaluation forms utilizing both Likert scale and open-ended responses. Overall, students were extremely complimentary about the workshop structure, content and communication skills teaching. They were especially appreciative of the opportunity to participate in their first interprofessional team experience. Conclusion: To address local needs, a well-received simulation-based workshop was created to train students in toxicology case management at EDMEs. Future work will include using this workshop in a just-in-time fashion before upcoming EDMEs and documenting students actual use of skills taught (Kirkpatrick level 3). The workshop will also be further modified to implement more detailed interprofessional objectives and can provide a venue for EM residents to practice teaching interprofessional education competencies as part of their CanMEDS Scholar role.

Introduction: As the value of interactive teaching becomes increasingly recognized, the Flipped Classroom model is receiving more attention in the medical education community. In this model, learners master core declarative knowledge through self-learning prior to class and then expand upon this learning with integrative class exercises. The objective of this study was to assess the effectiveness of the new Flipped Classroom in a Canadian Emergency Medicine postgraduate program. Methods: The residents and staff were educated on the new model. An online questionnaire was sent to all EM residents and staff who had participated in the program 9 months after implementation. The survey tool assessed the participants opinions on utility, time-management, effectiveness in learning material, sustainability, collaboration with other members and overall impressions. Resident scores on national preparatory examinations including the Canadian In-Training Examination (CITE) and the American Board of Emergency medicine (ABEM) were compared before and after implementation of the new model. Results: Teaching staff were trained in the Flipped Classroom model and the majority of teaching sessions for the 2016 academic year were carried out using this paradigm. In addition, third year postgraduates received intensive training in the theory and implementation of interactive teaching techniques. A curriculum renewal committee generated objectives for each teaching session and suggested materials for learner pre-reading. Conclusion: Overall, both residents and staff physicians indicated that the flipped classroom model is a better format for EM academic day learning. Residents and staff collaborated more and felt more engaged during academic day. Residents spent more time preparing for the sessions with the new model, while staff spent less time preparing. Paired comparisons of same residency years for test exam scores using Wilcoxon signed-rank test showed an improvement in both CITE and ABEM exam test scores. In conclusion, the new flipped classroom model produced improvements in educational experience, satisfaction, and test examination scores.

Introduction: Advanced care planning (ACP) and Goals of Care (GOC) discussions are becoming increasingly common in our emergency departments (ED). The national ACP task group has found that the majority of Canadians have not had prior ACP/GOC discussions, nor have they obtained proper documentation of their wishes. The task of having these difficult but important conversations falls frequently to the ED. Despite this, our emergency medicine (EM) residents receive little formal training in ACP discussions. To address this need, we developed and implemented a workshop in ACP/GOC conversations for the University of Alberta EM academic curriculum. Methods: A literature search was performed to identify best practices for ACP discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked to identify previous difficult ACP discussions and highlight aspects of these cases that were challenging in the ED environment. These experiences, best practices and published APC curricula informed the development of a 3-hour case-based workshop that was implemented in the 2016/17 academic year for EM staff and residents. Results: Cases utilized in the workshop emphasized common ACP/GOC situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC whose family did not accept the GOC designation. Case 2: A 72 year old with multiple comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with decreased LOC whose family asks for an ACP discussion in the ED. Participants were divided into groups (5-6 members). Each small group analyzed and discussed each case before the participants reconvened and discussed their opinions in one large group. ACP experts from palliative care, emergency medical services and EM facilitated the discussions highlighting the best practices from the literature for each case reviewed. Pre and post Likert surveys were distributed to workshop participants to assess changes in confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically significant improvement in learner confidence within the following areas (N=21; P<0.05): identifying patients appropriate for GOC discussions, initiating GOC discussions, and identifying barriers to GOC, in the ED. The majority (89%) of participants agreed the workshops should become part of our academic curriculum. Conclusion: An ACP/GOC workshop was successfully implemented and further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead, we will look at using other teaching modalities such as simulation to further enhance the delivery of the curriculum. We will also attempt to capture defined physician behaviors (e.g. documenting GOC in the ED chart, sending letters to family physicians documenting GOC discussions) to gauge uptake of the workshop principles into clinical practice.

Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Mircroskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Endotracheal intubation is a complex task with a clinically significant complication and failure rate. Methods: Two doctors and three nurses developed stepwise team microskills checklist from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 36 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. The microskills checklist was used in four phases: 1. Group discussion of each microskill step 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback. Changes are recorded. 3. Total task run though without interruption. Changes are recorded. 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Results. Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 13/30, RNs 7/16. The commonest changes in practice were patient positioning (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 4.8/5). Conclusion: Microskills checklist facilitate endotracheal intubation with a bougie skill development in interprofessional teams in this provisional analysis.

Introduction: Medical images (e.g. radiographs) are the most commonly ordered tests in emergency medicine. As such, emergency medicine physicians are faced with the task of learning the skill of interpreting these images to an expert performance level by the time they provide opinions that guide patient management decisions. However, discordant interpretations of these images between emergency physicians and expert counterparts (e.g. radiologists) is a common cause of medical error. In pediatrics, this problem is even greater due to the changing physiology with age. Methods: ImageSim (https://imagesim.com/) is an evidence-based on-line learning platform derived and validated over an 11 year period (https://imagesim.com/research-and-efficacy/). This learning system incorporates the concepts of cognitive simulation, gamification, deliberate practice, and performance-based competency in the presentation and interpretation of medical images. Specifically, ImageSim presents images as they are experienced in clinical practice and incorporates a normal to abnormal ratio is representative of that seen in emergency medicine. Further, it forces the participant to commit to the case being normal or abnormal and if abnormal, the participant has to visually locate the specific area of pathology on the image. The participant submits a response and gets text and visual feedback with every case. After each case, the participant gets to play again until they reach a desired competency threshold (80% is bronze resident; 90% silver staff emergency medicine physician; 97% gold radiologist). Importantly, the learning experience also emphasizes deliberate practice such that the learning system provides hundreds of case examples and therefore each participants performance has the opportunity to improve along their individual learning curve. Results: Course selection was made based on known medical image interpretation knowledge gaps for practicing emergency physicians. Currently, ImageSim live courses include pediatric musculoskeletal radiographs (2,100 cases, 7 modules) and pediatric chest radiographs (434 cases). In 2018, we will also release a pediatric point-of-care ultrasound course (400 cases, 4 modules) and the pre-pubertal female genital examination (150 cases). For a demo, go to https://imagesim.com/demo/. Using ImageSim, the deliberate practice of about 120 cases (1 hour time commitment) increases accuracy on average by 15%. Currently integrated into 10 emergency medicine training programs and there are about 300 continuing medical education world-wide participants. Conclusion: While acquiring mastery for these images may take years to acquire via clinical practice alone, this learning system can potentially help achieve this in just a few hours.

Introduction: Global Emergency Medicine (Global EM) is growing rapidly as an academic niche in Canada. An increasing number of Canadian emergency physicians work internationally as part of their practice, and trainees consistently seek out international projects and electives. For the most part however, residents have had to create their own training opportunities as formal Global EM fellowship training has been lacking in Canada. To address this identified need, Queens University established a Global EM fellowship, the first of its kind in the country. Methods: The fellowship is designed to provide the skills necessary for an academic career in Global Emergency Medicine. Curriculum and objectives are modeled on similar well-established fellowships in the United States. Areas of expertise include emergency medicine systems development, humanitarian medicine, disaster response, public health, tropical medicine, research, administration and education. Fellows have the opportunity to tailor their training according to their specific interests within these domains. Importantly, the fellowship provides direct mentorship from academic global EM and public health physicians, and networking opportunities within the global health sphere. Results: The two-year fellowship curriculum is divided between: 1) coursework to complete a Master of Public Health (MPH) Degree 2) fieldwork 3) relevant international emergency medicine training courses and 4) clinical work in the emergency departments at the Kingston Health Sciences Center. The Queens Global EM fellowship admitted its first fellow in August 2017. To date, the inaugural fellow has completed the MissionCraft Leadership in Disaster Relief course as well as a Humanitarian U Disaster and Response course, in addition to submitting a research grant as a co-principal investigator, starting coursework for an MPH degree and giving several invited lectures on humanitarian medicine. The fellow also travelled to Lebanon to support research in collaboration with aid organizations responding to the Syrian crisis. Upcoming fieldwork involves teaching at a newly established emergency medicine residency program in Haiti as well as a humanitarian crisis deployment. Conclusion: In response to a lack of formal international emergency medicine training opportunities in Canada, Queens University has established a Global Emergency Medicine fellowship. The fellowship aims to provide protected time, access to field opportunities and dedicated mentorship to develop the skills necessary to succeed as an academic Global EM physician. We believe it provides a unique opportunity to significantly expand fellows experiences in global health fieldwork, education and research while continuing to practice in a Canadian tertiary emergency department.

Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years of age with fractures: to 1) improve the proportion who receive analgesic medication from 35% to 50%; 2) improve the proportion who have a documented pain score from 23% to 50%, and 3) reduce median time to analgesia from 59 minutes to 30 minutes, within 1 year. Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children <17 years with a diagnosis of fracture who have a documented pain score, proportion who receive an analgesic medication, and minutes to analgesia. The measure for procedural pain was the proportion of children <12 years who receive topical anesthetic prior to a needle procedure for a laboratory test. Length of stay for pediatric patients and all patients were balancing measures. Run charts were used to detect special cause. Difference in proportions were compared using 2. Final analysis will include interrupted time series. Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (p<0.001). For children with fractures, the proportion with pain scores increased from 23% to 35% (p<0.001), proportion receiving analgesic medication increased from 35% to 42% (p<0.001), and median minutes to analgesia decreased from 59 to 43. Insufficient time points at this stage preclude identification of special cause. Conclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.

Introduction: For patients with chest pain, the target time from first medical contact to obtaining an electrocardiogram (ECG) is 10 minutes, as reperfusion within 120 minutes can reduce the risk of death and adverse outcomes in patients with ST elevation myocardial infarction (STEMI). In 2007, Vancouver Coastal Health (VCH) began tracking key indicators including time to first ECG. The Vancouver General Hospital (VGH) Emergency Department (ED) has been troubled with the longest door to ECG times in the region since 2014. In 2016, the VGH ED Quality Council developed a strategy to address this issue, with an aim of obtaining ECGs on 95% of patients presenting to the VGH ED with active chest pain within 10 minutes of presentation within a 6 month period. Methods: The VGH ED Quality Council brought together frontline clinicians, ECG technicians, and other stakeholders and completed a process map. We obtained baseline data regarding the median time to ECG in both patients with STEMI and all patients presenting with chest pain. Root cause analysis determined two main barriers: access to designated space to obtain ECGs, and the need for patients to be registered in the computer system before an ECG could be ordered. The team identified strategies to eliminate these barriers, identifying a dedicated space and undergoing multiple PDSA cycles to change the workflow to stream patients to this space before registration. Results: Our median times in patients with STEMI have gone from 33 minutes to 8 minutes as of June 2017. In all patients presenting with chest pain, we improved from a median of 36 to 17 minutes. As of April 2017 we are obtaining an ECG within 10 minutes in 27% of our patients, compared to 3% in 2016. Given the limitations in our data extraction process, we were not able to differentiate between patients with active chest pain versus those whose chest pain had resolved. Conclusion: By involving frontline staff, and having frontline champions providing real time support, we were able to make significant changes to the culture at triage. We cultivated sustainability by changing the workflow and physical space, and not relying on education only. While we have improved the times for our walk-in patients, we have not perfected the process when a patient moves immediately to a bed or presents via ambulance. Implementing small changes and incorporating feedback has allowed us to identify these new challenges early.

Introduction: Physician Initial Assessment (PIA) time at the Montfort Emergency Department (ED) in Ottawa is one of the longest in the province. PIA, Length of Stay (LOS), and Left Without Being Seen (LWBS) are all performance measures which impact hospital funding through the pay for results (P4R) system. Increased PIA times negatively impact hospital funding, patient satisfaction and may be correlated to patient safety. Our aim was to examine whether having a physician at triage during the last hour of their shift decreased PIA time, LOS, and LWBS rate, and also to overall improve patient care received in the Emergency Department. Methods: During the last hour of five different Emergency Department (ED) shifts (14-15h, 16-17h, 19-20h, 22-23h, 23h-00h), the physician worked with a designated registered nurse, evaluating patients in a room adjacent to triage and the waiting room. The current study evaluated the effectiveness of having a physician perform initial assessments at triage (including history, physical and ECG) and assess the impact on PIA time, LOS, and LWBS during the specific hours that a physician is at triage. This is a pre-post retrospective study. Baseline data was collected retrospectively over a period of 20 weeks prior to the intervention (between January 2017 and June 2017). Intervention data was collected over a period of 20 weeks starting in June 2017. Statistical process control (SPC) methodologies were then applied to the pre-post data of continuous variables. PIA time and LOS averages were obtained for each hour in which the physician was stationed at triage. I (XmR) charts were used for statistical analysis. Analysis was done using QI macros in Microsoft Excel. Results: Reductions in PIA times of 8 minutes (14-15h), 16 minutes (16-17h), 30 minutes (19-20h), 72 minutes (22-23h) and 88 minutes (23h-00h) were demonstrated across the 5 shifts throughout the trial period. No clear increase in LWBS wait times were demonstrated. Overall ED volumes increased modestly over the course of the intervention. Overall ED LOS in the department decreased about 25 minutes over this same period. There were no other PIA or LOS reduction initiatives taking place in the ED over the trial period. Conclusion: The goal of this study was to have patients seen quickly by an emergency physician at triage who would perform a rapid initial assessment and respond to needs for pain management, and order urgent testing or imaging. In this study, PIA times improved after the process change for every time period tested. One possible limitation was that this intervention likely had less adherence at the beginning of the trial as the staff adjusted to the new shift flow. This seems to be reflected in the data, since an improved process change is demonstrated near the end of the trial period. The next step in quality care improvement is to look at lab and imaging data to evaluate the utilization of tests with a physician at triage.

Introduction: The 2015 CanMEDS framework requires all residency programs to increase their focus on Quality Improvement and Patient Safety (QIPS). We created a longitudinal (4-year), modular QIPS curriculum for FRCP emergency medicine residents at the University of Toronto (UT) using multiple educational methods. The curriculum addresses three levels of QIPS training: knowledge, practical skills at the microsystem level, and practical skills at the organization level. Aim Statement: To increase the UT FRCP emergency medicine residents absolute score on the QIKAT-R (Quality Improvement Knowledge Application Tool Revised) by 10% after the completion of the QIPS curriculum. Methods: Physicians and other healthcare professionals with QI expertise collaboratively designed and taught the curriculum. We used the QIKAT-R as the outcome measure to evaluate QI knowledge and its applicability. The QIKAT-R is a validated measure that assesses an individuals ability to decipher a QI issue within the healthcare context, and propose a change initiative to address it. The first cohort of residents completed the QIKAT-R prior to the first session in 2014 (pre) and at the completion of the curriculum in 2017 (post). Each response was anonymized and scored by physicians with QI expertise. The QIKAT-R scores and comments from course evaluations are used to make yearly iterative curriculum changes. Results: The QIPS curriculum was implemented in September 2014. All nine residents in the first cohort completed the curriculum; they demonstrated an absolute increase of 19.6% (5.3/27) in the mean QIKAT-R score (13.0 +/− 3.3 pre vs. 18.3 +/− 3.8 post, p=0.001). Of the pre-test responses, 26% were categorized as poor, 70% as good, and 4% as excellent, whereas of the post-test 11% of responses were categorized as poor, 37% as good, and 52% as excellent (p<0.001). Two iterative curriculum changes were made at the end of each academic year since 2014: (1) The time between sessions were decreased to promote knowledge retention, and (2) different PGY3 QI practical project options were provided to suit residents individual QI interests. QIKAT-R scores and resident feedback were used to evaluate the impact of the curriculum changes. Conclusion: A collaborative, modular, longitudinal QIPS curriculum for UT FRCP emergency medicine residents that met CanMEDS requirements was created using multiple educational methods. The first resident cohort that completed the curriculum demonstrated an absolute increase in QI knowledge and its applicability (as measured by the QIKAT-R) by 19.6%. Two PDSA cycles were completed to improve the curriculum with the change ideas generated from resident feedback. Ongoing challenges include limited staff availability to teach and supervise resident QI projects. Future directions include incentivising staff participation and providing mentorship for residents with a career interest in QI beyond what is offered by the curriculum.

Introduction: The administration of “to-go” medications in the Kelowna General Hospital Emergency Department was identified as an issue. Frequently, multiple administrations of “to-go” medication pre-packs were administered to individual patients on a frequent basis. In addition, the variability in “to-go” medication was substantial between providers. Recognizing the patient issues (addiction, dependency and diversion) and system issues (costs, risk) a team-based quality improvement initiative was instituted, utilizing a variety of quality improvement techniques. The aim was to reduce the number of “to-go” medications by half, within a year. Methods: The project began January 2015, and is ongoing. Multiple stakeholders were engaged within the emergency department; these included leaders of the physician, nursing and pharmacy teams, including an executive sponsor. Using change theory, and traditional Plan-Do-Study-Act (PDSA) cycles, an iterative methodology was proposed. The outcome measure proposed was number of “to-go” medications administered; secondary measures included number of opioid “to-go” and benzodiazepine “to-go“prescriptions. Balancing measures were the number of narcotic prescriptions written. Physician prescribing practice and nursing practice were reviewed at meetings and huddles. Individualized reports were provided to physicians for self-review. Data was collated at baseline then reviewed quarterly at meetings and huddles. Run charts were utilized along with raw data and individualized reports. Results: At baseline (January 2015), the number of “to-go” medications was 708. Over the next year, this value reduced to 459, showing a 35% reduction in “to-go”. Two years later (June 2017), this had reduced to 142, resulting in an overall reduction of 80% “to-go” medications. Secondary measures are currently under analysis. Further, no increase in prescribing of narcotics was seen during this time period. Conclusion: The administration of “to-go” medications from the emergency department has significant individual and societal impact. Frequently, these medications are diverted; meaning, sold for profit on the black market. Further, opioid prescribing is under increased scrutiny as the linkage between opioid prescriptions and addiction / dependency becomes more evident. This quality improvement initiative was successful for a number of reasons. First, we had strong engagement from the full emergency department clinical teams. The issue was first identified collaboratively, and teamwork and participation was strong from the outset. Second, we used individual and aggregate data to provide feedback on a regular basis. Third, we had strong support from our executive sponsor(s) who were able to support the efforts and champion and present the results locally, and now, throughout the Health Region.

Introduction: Patients in our ED were dissatisfied with their waiting experience, which resulted in patient anxiety and complaints. In 8 months, we aimed to (1) improve patient satisfaction with the ED waiting experience from triage to physician initial assessment by a 15% improvement in patients who rate their experience very good/excellent on a Likert Scale, and (2) improve patient knowledge of ED wait time by a 50% increase in understanding on a Likert Scale. Methods: We co-designed a display with ED patients to notify those in the waiting room of their wait process and wait time. The intervention was selected after root cause diagnostics including: Fishbone exercise, Pareto Diagram, and Driver Diagram. The display was co-designed with ED patients and improved via PDSA cycles to establish information displayed and how to incorporate it into the waiting experience. After co-design, a low-fidelity display was piloted in the waiting room. Results: A family of measures were evaluated using patient/provider surveys and hospital data metrics. Outcome measures were (1) percentage of patients who rated their ED experience as very good/excellent on a Likert scale, and (2) patients who had a clear/very clear understanding of their wait time on a Likert scale. Process measures were the percentage of patients who (1) looked at the wait time display, and (2) felt they could communicate their wait time to others. Balancing measures were clerk/nurse satisfaction and self-reported interruptions of patients asking wait time. Outcomes were tracked using statistical process charts and run charts. Following display implementation, patient rating of their ED experience and patient understanding of wait time showed positive improvement. Clerks/nurses were also more satisfied with their jobs and self-reported interruptions decreased. Conclusion: A low-fidelity wait time display co-designed with patients improved patient satisfaction and understanding of ED wait times. We plan to develop an automated electronic display that resembles the low-fidelity display and evaluate the impact of the intervention on the established measures. This intervention has the potential to be sustainable, feasible for other EDs, and require minimal upkeep costs.

Introduction: The effectiveness of intravenous alteplase is highly time dependent, and very short door-to-needle times (DNT) of 30 minutes or less have been reported in single centre hospitals, but never in an entire population. QuICR (Quality Improvement and Clinical Research) Alberta Stroke Program aimed to reduce DNT to a median of 30 minutes across the Canadian province of Alberta. Methods: We used the Improvement Collaborative Methodology from early 2015 to September 2016 with participation from all 17 Stroke Centres in Alberta. This methodology included 4 face-to-face workshops, site visits, webinars, data collection, data feedback, intensive process mapping, and process improvements. We compared data in the pre-intervention period from 2009-2014 (collected during the Alberta Provincial Stroke Strategy) to data in the post-intervention period from March 2016-February 2017 (collected during the QuICR DTN Collaborative). Data from January 2015-February 2016 were excluded, as improvements were being implemented during this time. Results: There were a total of 2,322 treated cases in the pre- and post-intervention periods. The results show that the median DNT dropped from 68 minutes (n=1846) in the pre-intervention period to 36 minutes (n=476) in the post-intervention period (p<0.001). There were reductions in DNT across all hospital types: median DNT dropped from 63 to 32 minutes in Urban Tertiary Centres (p<0.001), from 73 to 32 minutes in Community with 24/7 neurology (p<0.001), from 85 to 62 minutes in Community with limited/no neurology (p<0.001), and from 74 to 52.5 minutes in rural centres (p<0.001). Conclusion: There were 21.5 to 41 minute reductions in median DNT across all hospital types including smaller rural and community hospitals. A targeted multi-site improvement collaborative can be an effective intervention to reduce DNT across an entire population.

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

Introduction: Les patients souffrant dun arrêt cardiaque extra hospitalier (ACEH) sont fréquemment traités à laide de soins avancés en réanimation cardiovasculaire (SARC). Dans ce contexte, des bicarbonates de sodium sont parfois administrés à des patients en arrêt cardiaque réfractaire chez qui une acidose métabolique importante, une hyperkaliémie ou une intoxication est suspectée. Puisquil ny a que peu dévidences quant à cet usage, lobjectif de la présente étude est dévaluer lassociation entre le traitement à laide de bicarbonate de sodium (une dose ou plus) et le devenir (retour de circulation spontané et survie au congé) chez les patients souffrant dun ACEH. Methods: La présente étude de cohorte a été réalisée à partir des bases de données de la Corporation dUrgences-santé dans la région de Montréal entre 2010 et 2015. Les patients adultes ayant souffert dun ACEH dorigine médicale traités en préhospitalier par des paramédics de soins avancés prodiguant des SARC ont été inclus. Les associations dintérêt ont été évaluées initialement à laide de régressions logistiques univariées, puis à laide de régressions logistiques multivariées ajustant pour les variables sociodémographiques et cliniques pertinentes. Results: Un total de 1973 patients (1349 hommes et 683 femmes) dun âge moyen de 66 ans (±17) ont été inclus dans cette étude, parmi lesquels 77 (3,8%) ont reçu une dose de bicarbonate, 763 (37,5%) ont retrouvés un pouls en préhospitalier et 222 (10,9%) ont survécu jusquà leur congé de lhôpital. Sans ajustement, il y avait une association négative entre le traitement à laide de bicarbonates et le retour de circulation spontané (rapport de cotes [RC]=0,46 [intervalle de confiance {IC} 95% 0,27-0,79], p=0,005) et la survie au congé (RC=0,21 [IC 95% 0,05-0,86], p=0,030). Cependant, ces associations nétaient plus significatives suite à lajustement pour les autres covariables (RC ajusté=0,63 [IC 95% 0,34-1,18], p=0,15 et RC ajusté=1,69 [95% IC 0,29-10,01], p=0,56). Conclusion: Il ny a pas dassociation indépendante entre le traitement à laide de bicarbonates et le devenir chez les patients souffrant dun ACEH. Dans ce contexte, il serait adéquat de réaliser un essai clinique afin de trancher définitivement sur cette question.

Introduction: Emergency health care providers (HCPs) regularly perform difficult medical resuscitations that require complex decision making and action. Critical incident debriefing has been proposed as a mechanism to mitigate the psychological effect of these stressful events and improve both provider and patient outcomes. The purpose of this updated systematic review is to determine if HCPs performing debriefing after critical incidents, compared to no debriefing, improves the outcomes of the HCPs or patients. Methods: We performed a librarian assisted systematic review of OVID Medline, CINAHL, OVID Embase and Google Scholar (January 2006 to February 2017) No restrictions for language were imposed. Two investigators evaluated articles independently for inclusion criteria, quality and data collection. Agreement was measured using the Kappa statistic and quality of the articles were assessed using the Downs and Black evaluation tool. Results: Among the 658 publications identified 16 met inclusion criteria. Participants included physicians, nurses, allied health and learners involved in both adult and pediatric resuscitations. Findings suggest that HCPs view debriefing positively (n=7). One moderate quality study showed that debriefing can enhance medical student and resident knowledge. Several studies (n=8) demonstrated at least some improvement in CPR and intubation related technical skills. Debriefing is also associated with improved short term patient survival but not survival to discharge (n=5). Two studies reported benefits to HCPs mental health as evidenced by improved ability to manage grief and decreased reported symptoms of Post-Traumatic Stress Disorder (PTSD). Conclusion: We found HCPs value debriefing after critical incidents and that debriefing is associated with improved HCP knowledge, skill and well-being. Despite these positive findings, there continues to be limited evidence that debriefing significantly impacts long term patient outcomes. Larger scale higher quality studies are required to further delineate the effect of structured debriefing on patient and provider outcomes.

Introduction: Long-term outcomes following out-of-hospital cardiac arrest (OHCA) remain poor. Two-thirds of OHCA patients surviving to hospital admission die from neurological injuries, and of those discharged, one-third have irreversible cognitive disabilities due to cerebral ischemia. Near-infrared spectroscopy (NIRS) is a non-invasive imaging technique which is able to continuously detect regional cerebral oxygenation (rSO2). NIRS monitoring has been used to measure rSO2 during in-hospital cardiac arrest resuscitation. Our study is the first feasibility study of paramedics applying NIRS monitoring during OHCA resuscitation. Methods: One NIRS monitor (Equanox 7600; Nonin, Plymouth, MI, USA) was placed on an Emergency Response Unit (ERU) with York Region Paramedic Services. ERU paramedics were trained to apply the device to patients foreheads during OHCA resuscitation and record rSO2 until arrival at hospital or termination of resuscitation. Paramedics did not alter any aspect of patient care by using the NIRS monitor. They were instructed to press an action marker on the device during ACLS interventions (e.g. defibrillation, intubation, medications, etc). rSO2 data was later downloaded for analysis. Our feasibility criteria was to obtain >70% of data files with rSO2 data and >70% of data files with event markers. Results: Data was collected from 24 OHCA patients over a period of 10 months. 19 cases (79%) files contained rSO2 data and 17 cases (71%) had event markers. The rSO2 data present in each file varied widely from complete recording for the entire call duration to sporadic brief readings. Event markers varied from 1 to 10 markers spaced throughout the cases. Conclusion: This is the first study to demonstrate that the use of NIRS by paramedics as part of OHCA resuscitation is feasible. Future studies are required to determine how rSO2 monitoring can be used to guide OHCA resuscitation. The results of this study will help inform protocols for future studies evaluating the use of NIRS in the out-of-hospital setting.

Introduction: Recent reports suggest that up to 30% of medical interventions provide no benefit to patients. In a response to ED over-crowding, guidelines commonly exist to guide blood test ordering in patients waiting to see a physician. In many cases, this increases the use of tests without benefiting patients. We describe a quality improvement project designed to reduce the number of laboratory tests considered routine for waiting patients. Methods: A multidisciplinary group reviewed existing symptom-prompted nursing blood test guidelines for serum electrolytes and glucose, renal function tests, liver tests, lipase, toxicological tests and beta Human Chorionic gonadotrophin levels. Order sets were revised with tests eliminated from the routine panels that were not felt to routinely contribute to patient care. The new guidelines were communicated to nursing staff in a series of educational sessions, and the revised guidelines were posted at nursing stations. Physician ordering practice was not changed. A pre-post evaluation compared the period 1 December 2014, - 30 November 2015 with 1 December 2015 - 30 November 2016. Clinical outcomes and patient wait times were not evaluated. Results: The use of tests in these categories decreased 32% between the two periods, at a net saving of $210, 246c. The largest savings came from total protein (73% decrease), Creatine kinase (68%), chloride (64%), glucose (49%), and albumin (47%). Sodium/Potassium testing decreased by only 13%. The only increase in test ordering recorded was AST (3% increase). Conclusion: Simply changing symptom driven order sets resulted in significant savings to the system. In the era of Choosing wisely regular review of lab order sets is indicated. Further study is needed to assess the effect of these changes on patient flow and on clinical outcome.