Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is one of the major contributors to ED overcrowding, and an indicator of hospital-wide deficiencies in capacity and flow. Most indicators of ED overcrowding have measured either counts or percentages of patient subgroups (e.g. number/percentage of patients waiting in triage or number/percentage of admitted patients as compared to full ED census), or specific process time intervals related to patient movement through the hospital (e.g. Physician to Initial Assessment (PIA) time or total ED Length of Stay (EDLOS)). We sought to 1) devise an alternative measure of ED overcrowding that captured the dynamic and disproportionate resource utilization of admitted versus non-admitted patients in the ED, and to 2) determine the association of this measure with selected ED quality metrics for non-admitted patients. Methods: We conducted a retrospective multi-centre observational study at three very high-volume community hospitals in the Greater Toronto Area. Data on all patients visiting the ED during the period between January 1, 2015 and December 31, 2016 were included in the study. We calculated the total daily cumulative boarding time - or time to bed (TTB) - for each day of the study duration. The daily cumulative TTB was calculated as the time from decision to admit to transfer from the ED for all admitted patients within a 24-hour period. We conducted linear regression analysis to determine the association between our measured daily cumulative TTB and daily median and 90th percentile PIA and EDLOS times for non-admitted patients. Results: Preliminary results for 2015 indicate a total cumulative TTB time ranging from 50,973 hours to 191,093 patient-hours for the year, with daily mean cumulative TTB ranging from 140 524 patient-hours/day among the three hospitals. In all three hospitals, there was a statistically significant (p<0.01) positive association between daily cumulative TTB and both median and 90th percentile PIA times for all patients, and median EDLOS times for non-admitted CTAS 1 -3 patients. There was a statistically significant (p<0.05) positive association between daily cumulative TTB and 90th percentile EDLOS for non-admitted CTAS 1-3 patients in two of the three hospitals, with the third hospital showing a positive but non-significant association. Conclusion: Bed boarding constitutes a significant resource cost for EDs, and has a negative impact on timeliness of ED care for the general ED population, particularly more complex (CTAS 1-3) non-admitted patients.

Introduction: It is assumed that sexual assault cases presenting at Emergency Departments (ED) are frequently lost to follow-up and should be considered an eligible population for presumptive antimicrobial treatment of sexual transmitted infections (STIs) at initial assessment without lab confirmation. With the growing burden of antibiotic resistance, antimicrobial stewardship guidelines caution against this practice. Among sexual assault cases, our study evaluated STI prevalence, follow-up and retention patterns, and described the prevalence of STI presumptive treatment. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital is the only program in Ottawa offering emergency and forensic care for survivors of sexual assault and domestic violence. Descriptive statistics were used to summarize information on demographics, clinical presentation, STI testing and results using data from the SAPACP case registry (January 1 - December 31, 2015). Results: Among the 406 patients seen by the SAPACP, there were 262 (64.5%) sexual assault cases that were included in this analysis. STI testing was completed for 209 (79.8%) patients at the initial visit, 90 (43.1%) completed via urine nucleic acid testing (NAAT), 140 (67.0%) via culture swab and 20 (9.6%) via both. Laboratory results detected no cases of gonorrhea, 8 (3.8%) cases of chlamydia, 33(15.8%) cases of bacterial vaginosis (BV), 17 (8.1%) cases of yeast vaginitis and 16 (7.7%) indeterminate testing results. Antimicrobial STI presumptive treatment was given to 12 (5.7%) patients at the time of their initial visit prior to lab confirmation. Patient follow-up occurred in 172 (82.3%) patients, with all chlamydia cases treated. Of the 37 (17.7%) patients lost to follow up, 9 were positive for BV, 1 was positive for yeast and 10 were indeterminate, all of which may be underlying vaginal flora. Follow up testing/test of cure was completed in 91 (52.9%) of patients, with 4 (2.3%) positive results, all of which were BV. Conclusion: In our ED, up to 15.8% of sexual assault patients had at least one laboratory confirmed STI and over 80% of all patients returned for follow-up. Our results show that it is safe and effective to only treat STI screen positive cases at follow-up, reducing the frequency of presumptive antimicrobial STI treatment. Benefits of this strategy include decreased patient side effects, cost savings and better antimicrobial stewardship.

Introduction: Upper gastrointestinal bleeding (UGIB) is a common Emergency Department (ED) presentation. Early endoscopic intervention, supported by Glasgow Blatchford Score (GBS) severity, has been shown to reduce re-bleeding rates and lower morbidity and mortality. However, emergent endoscopy is not necessary for all patients. Low-risk patients can be managed with outpatient follow-up. Other important management decisions such as blood transfusion (Hb <70) and use of proton pump inhibitors (PPI) also warrant evaluation. The aim of this study was to compare the timing and appropriateness of endoscopy and blood transfusion and proton pump inhibitor (PPI) use in a tertiary care setting to the standard of care. Methods: A retrospective cohort study was conducted to examine the management of patients presenting with UGIB to the ED in 2016 using a standard chart review methodology. TANDEM and EDIS (Emergency Department Information System) databases were queried to identify patients using specified ICD 10 codes and the CEDIS (Canadian Emergency Department Information System) presenting complaints of vomiting blood or blood in stool/melena. Outcome measures included: patient characteristics, the GBS to determine appropriateness of endoscopic intervention, diagnoses, blood transfusion indications and utilization of oral or intravenous PPIs. Data were entered into a REDCap database and analyzed using standard non-parametric statistical tests. Results: A total of 200 patients, 59% male (118/200), mean age 59 years (range 18 - 92 years) were included. The median GBS was 9. 79% of patients (157/200) underwent endoscopy during the hospital visit: 30% of patients with GBS 0-3 (13/43) and 80% patients with GBS 4 (125/157) underwent endoscopy 24 hours. The two most common endoscopic diagnoses were peptic ulcers (39%, 61/157) and varices (18%, 28/157), while 14% (22/157) had a normal diagnosis or mild gastritis. 174/200 patients (87%) were given IV or oral PPI in the ED whereas the remaining 26 (13%) did not receive PPI in hospital. 46% of patients (89/194) received blood transfusion, but only 51% (45/89) were administered based on the 70 g/L threshold while in 40% (36/89) of patients the less restrictive threshold of 90 g/L was used. Conclusion: A majority of UGIB patients presenting to a tertiary hospital ED appropriately received endoscopy 24 hours based on a GBS score 4. PPI use was appropriate but a proportion of patients received inappropriate blood transfusions.

Introduction: On March 16 2017, emergency departments and urgent care centres (collectively, EDs) in Calgary saw 3 times the number of fall-related ED visits, and 8 times the number of ED orthopedic consultations and admissions than the daily average for March 2014-2016. Fall-related injuries have significant associated morbidity and burden of disease, as well as cost to the health care system, caregivers and society. The purpose of this study was to use regression analysis to generate best fit models and identify weather and temporal variables which predict the frequency of fall-related ED visits, orthopedic consultations and admissions in winter (November-March). Methods: Daily number of ED visits, orthopedic consults, and orthopedic admissions for presenting complaint of Lower Extremity Injury, Upper Extremity Injury, or with an ED diagnosis of Fracture or Fall, were obtained for winter months from November 1 2013 to March 31 2017 from the Alberta Health Services ED database. Weather data was obtained from Environment Canada. Linear and multiple regression were performed to evaluate the predictive value of individual weather and temporal parameters, and derive the best-fitting model to predict the number of ED visits, orthopedic consultations, and orthopedic admissions. Results: Individual predictive factors (p<0.05) were month, temperature, overnight temperature drop from >0C to <0C, day of the week, amount of snow on the ground at 05:00, post-chinook day (chinooks are a warm winter wind in Calgary that can cause large temperature swings), maximum wind gust speed, and presence of precipitation. The best-fit multivariable models predicting fall-related ED visits (F-stat=15.36, R2=0.171), orthopedic consults (F-stat=6.369, R2=0.048), and orthopedic admissions (F-stat=8.658, R2=0.126) were statistically significant (probability of F-statistics all <0.0001). Conclusion: This study is, to the best of our knowledge, the first to use multiple regression to compute models using weather and temporal variables that can predict fall-related ED visits, orthopedic consults and admissions. This information could be used to alert the population regarding an increased fall and fracture risk ahead of the weather occurrence, as well as municipal snow and ice clearing services, who may be able to mitigate that risk. The ability to predict the frequency of fall-related injuries could enable EDs, EMS, orthopedic services, and hospitals to adjust resource and staffing allocation in anticipation of increases in fall-related injuries.

Introduction: Teamwork skills are essential in emergency presentations. When training medical students to manage acute care cases, simulation is frequently the educational tool. However, simulation content is often medically-focused, and post-simulation debriefs may not prioritize discussion of teamwork skills, as time is limited. Furthermore, debriefing both medical and teamwork aspects of a case may add to the learners cognitive load. This innovation uses an escape game as a non-clinical simulation to gamify teamwork skills training, with a focus on the collaborator CanMEDS role. In the entertainment industry, escape games are activities where teams solve a series of puzzles together to ultimately escape a room. Methods: 2 groups of 5 second-year medical students piloted the escape game, created within a simulation theatre, designed to surface teamwork competencies under the four University of Calgary Team Scheme domains (adapted from CIHCs National Interprofessional Competency Framework and TeamSTEPPS): Leadership/Membership, Communication, Situation Monitoring, and Collaborative Decision-Making/Mutual Support. During the game, facilitators noted examples of students strengths and challenges in demonstrating teamwork competencies. Post-game, a debrief and written reflective exercise enabled students to analyze successes and challenges in demonstrating teamwork competencies, propose solutions to teamwork challenges, and write 3 goals to improve teamwork skills. All competencies listed under each Team Scheme domain represented themes used in a thematic analysis to uncover students reported teamwork challenges. Results: Each escape game is a 30-minute teamwork activity where 5 students collaborate to complete 8 puzzles, which do not require medical knowledge, in order to win. Briefing is scheduled for 15-minutes, whereas post-game debriefing and reflection is 45-minutes. Conclusion: Escape games can highlight strengths and challenges in teamwork and collaboration amongst second-year medical students. Every competency under the Team Scheme domains was highlighted by the escape game pilots, touching on both strengths and challenges, for which students demonstrated, debriefed, and reflected upon. Students self-documented teamwork challenges include issues surrounding task-focused, closed-loop communication, and frequent reassessments. Advantages of this innovation include its use as a learning progression towards acute care simulations, portability and affordability, potential interprofessional use, and customizability. Additional training time may be required to orient facilitators to this atypical simulation. The escape game will launch in MDCN490 for second-year medical students and is scheduled prior to their acute care simulations. Further teamwork challenges identified at that time will help inform teamwork curriculum development for year 3.

Introduction: Substance and opioid misuse present significant illness burdens in Emergency Departments (EDs). Understanding risk factors for mortality in these patients is urgently needed to allow targeted prevention. This studys objective was to determine whether frequent ED use is independently associated with mortality among patients with substance and opioid misuse, and secondarily, whether degree of frequent use influences mortality risk. Methods: This is a retrospective cohort study in Alberta, Canada. National Ambulatory Care Reporting System ED data was linked to Vital Statistics mortality data using postal code, birthdate, and sex. All adults (18 years old at index visit, i.e. first visit made in the study year) with substance or opioid misuse (defined by ICD-10 codes) from April 1, 2012 to March 31, 2013 were included. Frequent use was defined by 5 ED visits in the 12 months prior to index visit. The primary outcome was mortality within 90 days, and secondarily, within 30 days, 365 days, and 2 years post-index visit. Mortality was compared using Kaplan-Meier curves and Cox regression adjusting for age, sex and income. Degree was examined by subcategorizing frequent use into 5-10, 11-15, 16-20, and >20 visits. Results: Overall, 16,389 patients made 24,880 visits for substance misuse, and 1787 patients made 2241 visits for opioid misuse. Frequent vs. non-frequent substance misusers were older, more often female, lower income, more often of rural residence, and arrived more by ambulance for lower acuity visits that were hospitalized less often. Compared to frequent substance misusers, frequent opioid misusers were more often female, of non-rural residence, arrived less often by ambulance, and made higher acuity visits that were hospitalized more often. Among substance misuse patients, 97.1% (95% CI: 96.6, 97.7) of frequent users vs. 98.0% (95% CI: 97.7, 98.2) of non-frequent users were alive at 2 years. Frequent use was significantly associated with mortality at 365 days (HR 1.36 [95% CI: 1.04, 1.77]) and 2 years (HR 1.32 [95% CI: 1.04, 1.67]) but not at 90 or 30 days. Subcategorized by degree, frequent use was significantly associated with mortality only for patients with >20 visits/year at 365 days (HR 1.88 [1.03, 3.44]) and 2 years (HR 1.89 [1.10, 3.22]). Among opioid misuse patients, there was no difference in mortality between frequent and non-frequent ED users at any time point. However, subcategorized by degree, a significant association was seen for those with 16-20 visits/year at 365 days (HR 3.62 [95% CI:1.13, 11.66]), and 2 years (HR 3.37 [95% CI: 1.05, 10.81]). Conclusion: In substance misuse patients, frequent ED use was significantly associated with long-term but not short-term mortality. Mortality risk for substance and opioid misuse patients was concentrated in extremely frequent users suggesting that the highest frequency presenters should be targeted for prevention.

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 and those without a D-dimer test were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.

Introduction: At Sunnybrook Health Sciences Centres Emergency Department (ED), delays occurred in reporting positive microbiology culture results of patients discharged from the ED. Follow-up of culture results was driven by a manual paper based process that was inefficient and resulted in a one to three day delay in reporting results. The previous system was time consuming, labour intensive and prone to human error. Timely reporting of microbiology culture results is important to ensuring that patients receive optimal care. The aim is that >80% of positive microbiology culture results of patients discharged from Sunnybrook Health Sciences Centre ED will be followed-up within 24 hours of results being available from the lab. Methods: Outcome Measure Percentage of positive culture results followed up within 24 hours Process Measure Time from availability of culture results from lab to completion of patient follow-up Balancing Measure Number of positive culture results not displayed in ED server Change Idea Electronically push positive culture results to an ED server that is periodically checked daily and acted upon. An electronic interface was created to capture positive results from the microbiology lab in real time. Results: There was a 45 hour reduction in the mean time to complete a patients follow-up of culture results (59 hours pre vs. 14 hours post, p=0.03). We surpassed our aim of >80% follow-up within 24 hours. Conclusion: A significant reduction to completing a patients follow-up of microbiology culture results was achieved by automating the availability of results and eliminating the manual process previously used in relaying results from the microbiology lab to ED. This new process has the following benefits: 1) Improves timely reporting of culture results to patients, that may require initiation or change in antibiotics 2) Enhanced patient safety due to elimination of human error 3) Decreased workload due to elimination of batching of results and data entry 4) Entire process is streamlined, since only positive culture results are transmitted for follow-up.

Introduction: Competency-based medical education (CBME) affirms that trainees will receive timely assessments and effective feedback about their clinical performance, which has inevitably raised concerns about assessment burden. Therefore, we need ways of generating assessments that do not rely exclusively on faculty-produced reports. The main object of this research is to investigate how data already collected in the electronic health record (EHR) might be meaningfully and appropriately used for assessing emergency medicine (EM) trainees independent and interdependent clinical performance. This study represents the first step in exploring what EHR data might be utilized to monitor and assess trainees clinical performance Methods: Following constructivist grounded theory, individual semi-structured interviews were conducted with 10 EM faculty and 11 EM trainees, across all postgraduate years, to identify EHR performance indicators that represent EM trainees independent and interdependent clinical actions and decisions. Participants were presented with a list of performance indicators and asked to comment on how valuable each would be in assessing trainee performance. Data analysis employed constant comparative inductive methods and occured throughout data collection. Results: Participants created, refined, and eliminated performance indicators. Our main result is a catalogue of clinical performance indicators, described by our participants, as reflecting independent and/or interdependent EM trainee performance that are believed to be captured within the EHR. Such independent indicators include: number of patients seen (according to CTAS levels), turnaround time between when a patient is signed up for and first orders are made, number of narcotics prescribed. Meanwhile, interdependent indicators include, but are not limited to, length of stay, bounce-back rates, ordering practices, and time to fluids. Conclusion: Our findings document a process for developing EM trainee report cards that incorporate the perspectives of clinical faculty and trainees. Our work has important implications for distinguishing between independent and interdependent clinical performance indicators.

Introduction: Cognitive bias is often cited as an explanation for diagnostic errors. Of the numerous cognitive biases currently discussed in the literature, availability bias, defined as the current case reminds you of a recent similar example is most well-known. Despite the ubiquity of cognitive biases in medical and popular literature, there is surprisingly little evidence to substantiate these claims. The present study sought to measure the influence of availability bias and identify contributing factors that may increase susceptibility to the influence of a recent similar case. Methods: To investigate the role of prior examples and category priming on diagnostic error at different levels of expertise, we devised a 2 phase experiment. The experimental intervention was in a validation phase preceding the test, where participants were asked to verify a diagnosis which was either i) representative of Diagnosis A, and similar to a test case, ii) representative of Diagnosis A and dissimilar to a test case, iii) representative of Diagnosis B and similar to a test case. The test phase consisted of 8 written cases, each with two approximately equally likely diagnoses(A or B). Each participant verified 2 cases from each condition, for a total of 6. They then diagnosed all 8 test cases; the remaining 2 test cases had no prior example. All cases were counterbalanced across conditions. Comparison between Condition i) and ii) and no prior showed effect of prior exemplar; comparison between iii) and no prior showed effect of category priming. Because cases were designed so that both Diagnosis A and B were likely, overall accuracy was measured as the sum of proportion of cases in which either was selected. Subjects were emergency medicine staff (n=40), residents (n=39) and medical students (n=32) from McMaster University, University of Washington, and Harvard Medical School. Results: Overall, staff had an accuracy (A + B) of 98%, residents 98% and students 85% (F=35.6,p<.0001). For residents and staff there was no effect of condition (all mean accuracies 97% to 100%); for students there was a clear effect of category priming, with accuracy of 84% for i), 87% for ii) and 94% for iii) but only 73% for the no prime condition (Interaction F= 3.54, p<.002) Conclusion: Although prior research has shown substantial biasing effects of availability, primarily in cases requiring visual diagnosis, the present study has shown such effects only for novices (medical students). Possible explanations need to be explored. Nevertheless, our study shows that with increasing expertise, availability may not be a source of error.

Introduction: Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes such as recurrent ED visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (< 25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level > 20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate > 110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up.

Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &/or history of fever and 2 or more signs of hypoperfusion (eg. SBP<90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index >1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.

Introduction: Pulmonary embolism (PE) is a diagnostic challenge, since it shares symptoms with other conditions. Missed diagnosis puts patients at a risk of a potentially fatal outcome, while false positive results leave them at risk of side effects (bleeding) from unnecessary treatment. Diagnosis involves a multi-step pathway consisting of clinical prediction rules (CPRs), laboratory testing, and diagnostic imaging, but the best strategy in the Canadian context is unclear. Methods: We carried out a systematic review of the diagnostic accuracy, clinical utility, and safety of diagnostic pathways, CPRs, and diagnostic imaging for the diagnosis of PE. Clinical prediction rules were studied by an overview of systematic reviews, and pathways and diagnostic imaging by a primary systematic review. Where feasible, a diagnostic test meta-analysis was conducted, with statistical adjustment for the use of variable and imperfect reference standards across studies. Results: The Wells CPR rule showed greater specificity than the Geneva, but the relative sensitivities were undetermined. Application of a CPR followed by with D-dimer laboratory testing can safely rule out PE. In diagnostic test accuracy meta-analysis, computed tomography (CT) (sensitivity 0.973, 95% CrI 0.921 to 1.00) and ventilation/perfusion single-photon emission CT (VQ-SPECT) (sensitivity 0.974, 95% CrI 0.898 to 1.00) had the highest sensitivity) and CT the highest specificity (0.987, 95% CrI 0.958 to 1.00). VQ and VQ-SPECT had a higher proportion of indeterminate studies, while VQ and VQ-SPECT involved lower radiation exposure than CT. Conclusion: CPR and D-dimer testing can be used to avoid unnecessary imaging. CT is the most accurate single modality, but radiation risk must be assessed. These findings, in conjunction with a recent health technology assessment, may help to inform clinical practice and guidelines.

Introduction: The GridlockED game is a serious game aimed at teaching junior learners about flow and organization in the emergency department(ED). With serious games, the mechanism of learning is thought to be via the gameplay experience. Objectives built into gameplay are aimed at teaching players about a specific concept; in this case, we hoped to teach players about interprofessional collaboration and basic mechanics that drive flow in the ED. However, before a player can be taught, he or she must be engaged and have a positive gameplay experience. From the GridlockED gameplay, we aim to explore how a players gameplay experience related to observed actions while playing the game, including participating in decision making and keeping the team organized. Methods: From April-August 2017, participants were invited to play 4 turns of a GridlockED game session. They were video recorded during gameplay. After playing the game, they were surveyed using the previously derived Game Experience Questionnaire (GEQ) to measure their gameplay experience. The videos were reviewed by two research team members (SH, EJ), tallying various observed game actions. We conducted Pearson correlation between players GEQ total score and their observed actions. Results: A total of 32 participants (13 attendings, 5 senior residents, 10 junior residents, and 4 nurses) played the game. The average total GEQ was 67.2/132 (SD=10.7), suggesting most players had a moderately good gameplay experience. The total GEQ score correlated with component subscores within the questionnaire. Overall observed activity correlated well with each observed action subtype. However, the GEQ total score did not correlate significantly with the total observed action (Pearsons r=0.18,p=0.32). GEQ total score was found to be moderately correlated to an observation that a player participated in determining strategy during gameplay (r=0.36,p=0.04). There was a moderate negative correlation between determining strategy during gameplay and teaching about the game (r=-0.37,p=0.04) or emergency medicine concepts (r=-0.47,p<0.01). Conclusion: The GEQ is internally consistent, but does not have a strong relationship to observed actions, suggesting that game experience does not necessarily correlate with observable actions. This suggests that players may be intellectually stimulated or engaged without necessarily completing any observable actions during gameplay.

Introduction: The CAEP annual meeting presents the latest evidence for clinical practice, but there has not yet been an appraisal of the abstracts presented at this conference. Therefore, we sought to evaluate the level of evidence of research presented at the annual meeting, and assess for trends over a five-year period (2013-2017). Methods: We conducted a scoping review that included all CAEP abstracts from 2013-2017, obtained through the Canadian Journal of Emergency Medicine. Two reviewers assessed eligibility and extracted data from abstracts individually, with conflicts resolved by a third reviewer. Qualitative research was excluded. Extracted data included type of presentation (ex. oral, poster), sample size, study design and type of study (therapeutic, prognostic, diagnostic, education, quality improvement, or systems-wide/economic analyses research). A level of evidence (LOE) was assigned using the 2011 Oxford Centre for Evidence-Based Medicine criteria. Results: Abstracts from 2014-2017 have been analyzed thus far, 1090 of which were eligible and 990 included. Inter-rater agreement for screening and data extraction was high ( value 0.87 and 0.84 respectively). Systems-wide/economic analyses research was the predominant type of study (28.6%, 283/990), followed by therapeutic (19.9%, 197/990) and education (19.9%, 195/990). The mean LOE was 2.81 (95% CI 2.77,2.85). The highest proportion of studies were of level III evidence (77.7%, 769/990), followed by level II (9.6%, 95/990) and level I evidence (7.8%, 77/990). 72.1% (124/172) of all level I and II abstracts were presented in 2016 and 2017. A significant change in LOE between years was evident (p<0.0001, chi-squared). The greatest proportion of level I and II abstracts were lightning oral (41.9%, 72/172), followed by posters (36.0%, 62/172). The best average LOE was observed for lightning oral (2.64, 95% CI 2.56, 2.72), with the poorest average LOE witnessed for moderated posters (2.90, 95% CI 2.83, 2.97). A significant difference was present in mean LOE between types of presentations (p<0.0001, one-sided ANOVA). Conclusion: The majority of abstracts were level III evidence. The lightning oral sessions had the greatest proportion of level I and II evidence presented. Recent years of the conference have also seen the presentation of a greater number of level I and II evidence, which may suggest a shift towards generating and disseminating higher level evidence in emergency medicine.

Introduction: Prior research has shown that audit and feedback (A &F) can be an effective tool for practice change. However, questions remain about how to optimize A&F. The objectives of this project were to determine if: 1) there are differences in practice between physicians who do, and do not, consent to receive a confidential report on their practice and; 2) if there is a relationship between consenting physicians self-predicted and actual practice. Methods: This was a prospective, cross-sectional study embedded in a larger quality improvement (QI) initiative to align physician practice with best evidence in the emergency department (ED) care of infants with bronchiolitis. All physicians practicing in the ED of a tertiary care pediatric hospital were offered the opportunity to consent to receive an individual, confidential data report on their practice. Prior to receiving their data, consenting physicians completed a survey which asked them to predict the proportion of bronchiolitic patients for whom they ordered diagnostic tests or treatments. We used chi-squared testing to compare the proportion of consenting and non-consenting physicians whose diagnostic test (Chest X-ray (CXR), viral study) and treatment (steroid, Ventolin) ordering was above the median for all ED physicians. We used Pearsons correlation to assess the relationship between consenting physicians self -predicted and actual practice. Results: 56% (37/66) of physicians consented to receive a data report. The median proportion of patients with an x-ray ordered was 20%, 63% of non-consenters were above the median, compared to 36% of consenters (X2 (1, N=66)=4.91 p=0.03). For viral testing, 31% of patients had a test ordered, with 50% of non-consenters and 50% consenters above the median (( X2 (1, N=66) =0 p=1); 11% of patients had steroids ordered, with 53% of non-consenters and 47% of consenters above the median ( X2 (1, N=66)=0.24 p-0.621); and 18% of patients had Ventolin ordered, with 60% of non-consenters and 42% of consenters above the median ( X2 (1, N=66) =2.2 p=0.138). There was a moderate correlation between physicians predicted and actual practice with respect to viral testing (r=0.67), but minimal correlation for CXR (0.05), steroids (r=0.17) or Ventolin (r=0.33) ordering. Conclusion: The finding that physicians have a limited ability to accurately predict their own performance emphasizes the importance of providing physicians with feedback. However, our results suggest that the consent process may be a potential barrier to effective A &F.

Introduction: Screening for organ and tissue donation is an essential skill for emergency physicians. In 2015, 4564 individuals were on a waiting list for organ transplant and 242 died while waiting. As Canadas donation rates are less than half that of other comparable countries, it is crucial to ensure we are identifying all potential donors. Patients deceased from poisoning are a source that may not be considered for referral as often as those who die from other causes. This study aims to identify if patients dying from poisoning represent an under-referred group and determine what physician characteristics influence referral decisions. Methods: In this cross-sectional unidirectional survey study, physician members of the Canadian Association of Emergency Physicians were invited to participate. Participants were presented with 20 organ donation scenarios that included poisoned and non-poisoned deaths, as well as one ideal scenario for organ or tissue donation used for comparison. Participants were unaware of the objective to explore donation in the context of poisoning deaths. Following the organ donation scenarios, a range of follow-up questions and demographics were included to explore factors influencing the decision to refer or not refer for organ or tissue donation. Results were reported descriptively and associations between physician characteristics and decisions to refer were assessed using odds ratios and 95% confidence intervals. Results: 208/2058 (10.1%) physicians participated. 25% did not refer in scenarios involving a drug overdose (n=71). Specific poisonings commonly triggering the decision to not refer included palliative care medications (n=34, 18%), acetaminophen (n=42, 22%), chemical exposure (n=48, 27%) and organophosphates (n=87, 48%). Factors associated with an increased likelihood to refer potential donors following overdose included previous organ and tissue donation training (OR=2.6), having referred in the past (OR=4.3), available donation support (OR=3.9), greater than 10 years of service (OR=2.1), large urban center (OR=3.8), holding emergency medicine certification (OR=3.6), male gender (OR=2.2, CI), and having indicated a desire to be a donor on government identification (OR=5.8). Conclusion: Scenarios involving drug overdoses were associated with under-referral for organ and tissue donation. As poisoning is not a contraindication for referral, this represents a potential source of donors. By examining characteristics that put clinicians at risk for under-referral of organ or tissue donors, becoming aware of potential biases, improving transplant knowledge bases, and implementing support and training programs for the organ and tissue donation processes, we have the opportunity to improve these rates and reduce morbidity and mortality for Canadians requiring organ or tissue donation.

Introduction: Aligning health systems appropriately to the needs of the elderly is an urgent global priority, according to the WHO. In Canada, ED length of stay has risen 16% for elderly patients in the last year. Agitation requiring chemical restraint is a common, high-risk problem for elderly in the ED. Improving outcomes in this heterogeneous population remain difficult due to inability to effectively identify and evaluate delirium, frailty, multi-morbidity, and incompatibility with the ED system. A data-driven approach to complex health problems is a recognized emerging tool for healthcare innovation. New opportunities for targeted quality improvement in the ED will be uncovered by identifying the clinical characteristics of elderly patients with agitation, and the system process factors that influence their outcomes. Methods: We studied 400 patients in a case-control study at two tertiary-care EDs over five years. Patients were randomly selected if age was greater than 75 years. 200 cases of patients who received an intravenous dose of haloperidol, midazolam and/or lorazepam were selected as a surrogate data marker for having agitation. Controls were randomly matched by age and ED diagnosis. Standardized clinical, systems and process variables were collected. We conducted a univariate analysis. Results: Elderly given intravenous medications for agitation had increased mortality (OR 3.8 CI: 1.6-10.7, p<0.001) and ED length of stay (27 vs. 15 hours, p<0.001). No statistical significance was found in clinical characteristics, CTAS scores, PRISMA7 frailty scores nor sentinel or return visits. There was no statistical difference in median hospital length of stay (8 vs. 6 days, p<0.70). No differences were found in median time from ED physician seeing a patient to first consultant request (73 vs. 83 mins, p=0.75). The largest time intervals contributing to ED length of stay were from first consultant request to hospital request (15 vs. 12 hours, p=0.056) and hospitalization delay (13 vs. 7 hours, p=0.45). Conclusion: Identification of high-risk elderly patients for targeted intervention through a data-driven approach is feasible and informative. Traditional clinical characteristics remain unhelpful in identifying and evaluating outcomes in elderly with agitation. We have identified a process factor that is clinically relevant and pragmatic to evaluate in our ED system. Future research focused on optimizing systems process factors to improve quality of elderly care should be prioritized.

Introduction: The optimal diagnostic strategy for children presenting to the Emergency Department (ED) with suspected appendicitis (SA), the most common non-traumatic surgical emergency in children, remains unclear. This study aims to identify which investigations and management priorities are preferred by Canadian surgeons prior to consultation from the ED. Methods: An internet survey was extended to practicing surgeons who are members of the Canadian Association of Pediatric Surgeons and Canadian Association of General Surgeons. Three case-based scenarios evaluated surgeons expected ED investigations and management for SA with varying severity of disease (simple - SA vs perforated - PA) and sex (male vs female). Differences across scenarios were determined by ANOVA and direct comparisons were reported using proportions and odds ratios with 95% confidence intervals. Results: Surveys were completed by 82 surgeons. Across the 3 cases, CBC (227/246, 92.3%) and urinalysis (188/246, 76.4%) were the sole investigations expected in >75% of responses. Expectations differed across cases for use of blood cultures (p<0.001), electrolytes (p<0.001), sexually transmitted infection testing (0.015) and ultrasound (US) (p<0.001). Blood cultures (26/82, 31.7% vs 4/82, 4.9%; OR 9.05 95%CI 2.88-37.33) and electrolytes (58/82, 70.7% vs 33/82, 40.2%; OR 3.59 95%CI 1.79-7.24) were expected more often in severe disease. US was expected more often in females (58/82,70.7% vs 25/82, 30.5%; OR 5.51, 95% CI 2.68-11.38). Expected management differed across cases for fluid boluses (p=0.01), intravenous (IV) analgesia (p<0.001) and antibiotics (p<0.001), with all differences attributed to severity of illness (fluids 73/82, 89.0% vs 59/82, 72.0% OR 3.16 95%CI 1.28-8.33; IV analgesia 66/82, 80.5% vs 42/82, 51.2% OR 3.93 95%CI 1.86-8.45; antibiotics 44/82, 53.7% vs 10/82, 12.2% OR 8.34 95%CI 3.59-20.44). Conclusion: Severity of illness and sex of the child impact the ED investigations and management expected by surgeons consulted for suspected appendicitis. Further research focusing on how these expectations influence patient outcomes should be conducted. Collaborative ED-surgery protocols for the diagnosis and management of acute appendicitis in children should be established.

Introduction: The emergency department (ED) is often the first point of access to the health care system for patients with an acute mental health crisis. Outpatient resources are limited, typically do not operate after hours, and patients and their families often lack sufficient information on where and how to access mental health services within their communities. The objective of this study was to determine which community healthcare resources patients attempted to access for their mental health condition prior to presenting to the ED. Methods: Between April 2016 to June 2017, a convenience sample of adult ( 18 years) patients presenting to an academic ED (annual census 65,000) with a mental health complaint were invited to complete a 23-item, paper-based survey. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 200 patients who completed the survey, mean (SD) age was 37 (16) years and 96 (48%) were male. 20 (10%) patients were brought to the ED involuntarily by police services. 175 (88%) had been previously diagnosed with a mental health condition, the most common being depression and/or anxiety (n=134, 67%). 47 (24%) patients indicated they were currently only connected to a primary care provider, while 94 (47%) patients indicated they had existing relationships with multiple mental healthcare providers. 117 (59%) patients attempted to see an alternative healthcare provider prior to coming to the ED. 78 (39%) patients had a pending scheduled appointment with a healthcare provider for their mental health condition, 44 (56%) of which were within 7 days of their ED visit, but chose to seek care in the ED. 38 (19%) patients either had a referral with no appointment date set, or had an impending mental health appointment scheduled more than 30 days from their ED visit. Conclusion: These findings suggest that most patients seeking ED care during a mental health crisis do so despite being connected to alternative healthcare providers and outpatient services. Future studies should attempt to determine reasons why patients with mental health conditions seek care in the ED, and examine barriers to mental health care in the community and outpatient setting.