Introduction: Despite revolutionary changes in the medical education landscape, journal club (JC) continues to be a ubiquitous pedagogical tool and is a primary way that residency programs review new evidence and teach evidence-based medicine. JC is a community of practice among physicians, which may help translate research findings into practice. Program representatives state that JC should have a goal of translating novel research into changes in clinical care, but there has been minimal evaluation of the success of JC in achieving this goal. Specifically, emergency medicine resident perspectives on the utility of JC remain unknown. Methods: We designed a multi-centre qualitative study for three distinct academic environments at the University of British Columbia (Vancouver, Victoria and Kelowna). Pilot testing was performed to generate preliminary themes and to finalize the interview script. An exploratory, semi-structured focus group was performed, followed by multiple one-on-one interviews using snowball sampling. Iterative thematic analysis directed data collection until thematic sufficiency was achieved. Analysis was conducted using a constructivist Grounded Theory method with communities of practice as a theoretical lens. Themes were compared to the existing literature to corroborate or challenge existing educational theory. Results: Pilot testing has revealed the following primary themes: (1) Only select residents are able to increase their participation in JC over the course of residency and navigate the transition from peripheral participant to core member; (2) These residents use their increased clinical experience to perceive relevance in JC topics, and; (3) Residents who remain peripheral participants identify a lack time to prepare for journal club and a lack of staff physician attendance as barriers to resident engagement. We will further develop these themes during the focus group and interview phases of our study. Conclusion: JC is a potentially valuable educational resource for residents. JC works as a community of practice only for a select group of residents, and many remain peripheral participants for the duration of their residency. Incorporation of Free Open-Access Medical Education resources may also decrease preparation time for residents and staff physicians and increase buy-in. To augment clinical impact, the JC community of practice may need to expand beyond emergency medicine and include other specialties.

Introduction: An emergency department visit may represent a sentinel event for someone who is older and frail, signalling a slide into dependence and functional decline. The gold standard for the treatment of frail older adults is a comprehensive geriatric assessment, involving consideration of multiple domains including mobility and function in activities of daily living. Despite this, when a chart audit was conducted in a Canadian metropolitan emergency department, none of the patients age 65 and older had a documented assessment of their function or mobility. In response, an occupational therapy program was implemented. The goals of this program were to reduce the number of unnecessary hospital admissions related to patient functional impairments, and to increase function, safety, and independence for patients upon discharge from the emergency department. Methods: The pilot project, which was completed in 2013, was evaluated using a mixed methods approach. Positive patient outcomes at that time included a reduction in avoidable admissions and better support for patients upon discharge from the emergency department. A survey of emergency department staff indicated that occupational therapy consultation added value to the diagnostic and discharge planning processes. However, due to changes in administrative priorities, several service redesigns were required. Multiple PDSA cycles were completed, and the development of a logic model guided and focused program development. Results: A reassessment of program objectives was conducted using 2015 data, which found that the number of patients seen by the occupational therapist remained the same, as did the percentage of patients discharged with support of occupational therapy intervention, such as provision of adaptive equipment or referral to community rehabilitation referrals. The percentage of patients discharged due to occupational therapy as a primary contributing factor rose slightly, and staff satisfaction with the program remained high. Conclusion: This evaluation proves that the provision of occupational therapy services in the emergency department is sustainable, benefits patients, and can be incorporated into the emergency department workflow and culture.

Introduction: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making many emergency medicine physicians have pursued specialized training to perform point of care biliary ultrasound in the emergency department (BUSED). The purpose of this study was to determine the usefulness of BUSED in predicting the need for surgical consultation and intervention for biliary disease. Methods: A retrospective study of 283 consecutive patients visiting the emergency department who received a BUSED scan from December 1, 2016 to July 16, 2017. Physician interpretations of the BUSED scans were collected from the electronic image storage and interpretation system. Additional data was collected from the electronic health record including lab values, the subsequent use of diagnostic imaging, and outcomes data including disposition, surgical consultation or intervention, and 28 day follow up for representation or complication. Descriptive statistics and logistic regression were performed. Results: Of the patients who received a biliary POCUS scan, 29% were referred to general surgery, and 43% of those referred proceeded to eventual cholecystectomy. Factors found to be independently predictive of surgical intervention on point of care BUSED scans included presence of gall stones (OR 13.01, 95%CI 5.02 to 27.1) and increased gallbladder wall thickness (OR 6.01, 95%CI 1.7 to 11.1). A total of 30% of patients receiving BUSED required at least one additional, radiology based imaging test (CT or diagnostic US). Average emergency department length of stay was substantially longer for those who required additional imaging as compared to those who were able to be diagnosed by BUSED alone (16.1 versus 5.2 hours, 10.9 hours 95%CI 10.6 11.2, p<0.05) . Conclusion: Point of care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gall stones and increased gall bladder wall thickness are highly predictive of the need for surgical intervention. Future, prospective studies are warranted to determine if point of care sonography is sufficient to proceed to surgery in select cases of uncomplicated biliary disease.

Introduction: Background: Studies in the US have demonstrated that many primary care staff and offices are inadequately prepared for paediatric emergencies. Although the Canadian Paediatric Society (CPS) recently reaffirmed their Guidelines for Paediatric Emergency Equipment and Supplies for a Physicians Office, no evaluation has been made regarding the impact of publishing these recommendations, or on the state of preparedness for paediatric emergencies in family physician offices. Objectives: The aim of this study was to evaluate awareness and adherence of family physicians in Ontario to the CPS guidelines on preparedness for paediatric emergencies. Methods: We conducted a province-wide, cross-sectional survey of 749 randomly selected family physicians. Participants were asked to complete a 14-question survey regarding clinic characteristics, incidence of paediatric emergencies, and preparedness of the clinic in the case of a paediatric emergency. Ethics approval was obtained from the regional Ethics Review Board. Results: 104 physicians responded to our Ontario survey (response rate of 14.8%). 71.2% of respondents reported seeing more than 10 children per week, and 58.7% and had experienced at least one paediatric emergency in the past year. The proportion of physicians reporting paediatric emergencies within the last year increased with the number of children seen - 37.9% of physicians who saw fewer than 10 children per week reported an emergency, compared to 85.7% of those who saw more than 40 children per week. 85.6% of respondents reported that they were unaware of the CPS guidelines on paediatric emergency preparedness. Only 9.6% of respondents were aware of the guidelines, and even fewer, 3.8% had read them. Of the physicians who were unaware of the guidelines, 4.5% [CI=0.2, -0.09] engaged in mock code sessions, 29.2% [CI=0.2, 0.2] were up-to-date on Paediatric Advanced Life Support (PALS), 1.1% [CI=0.03, -0.01] had written protocols outlining safe transport of children to hospitals, and 50.6% [CI=0.4, 0.6] stocked half or more of the recommended supplies. In comparison, of the physicians who were aware of the guidelines, 14.3% [CI=0.3, -0.04] engaged in mock code sessions, 35.7% [CI=0.1, 0.6] were up-to-date on PALS, 7.1% [CI=0.2, -0.06] had written protocols, and 78.6% [CI=0.8, 0.8] stocked half or more of the recommended supplies. Conclusion: A large proportion of respondents had experienced at least one paediatric emergency in the past year, but were overall underprepared. The majority of respondents, 85.6%, were not aware of the guidelines, compared to 9.6% who were aware of them. However, offices with the latter were more adherent to the guidelines recommendations. It will be important for CPS to consider how to further advocate for paediatric emergency preparedness in clinics that see children regularly.

Introduction: Asthma and/or chronic obstructive pulmonary disease (COPD) exacerbations often result in emergency department (ED) visits. This study examined the health-related personnel providing regular care to patients with asthma and/or COPD, as well as, explored the coordination of care between the ED and outpatient settings. Methods: Descriptive cross-sectional examination of patients presenting with asthma and/or COPD exacerbations to two EDs in Edmonton between August and December 2017. Using patient interview methods information on demographics, established health care connections and health system use was collected; information on consultations, disposition and referrals was collected through chart review methods. Results: A total of 50 patients were recruited (14 patients with asthma and 36 patients with COPD). Most of the patients with asthma were female (64%) and their median age was 36 years (interquartile range [IQR]: 29, 46); sex was evenly distributed among the patients with COPD and their median age was 68 years (IQR: 61, 78). The majority reported having a family doctor (86% of the patients with asthma and 94% of the patients with COPD). On the day of admission to the ED, 29% of the patients with asthma visited their family doctor while 42% of the patients with COPD visited their Respirologist; these doctors referred >70% of the patients to the ED. While in the ED, consultations were requested in 21% of the patients with asthma (all to Pulmonary) and in 78% of the patients with COPD (evenly divided between Medicine and Pulmonary). Transition coordinators and social workers were involved in the ED care of <15% of the patients with COPD. Most patients with asthma were discharged home (86%) and 64% of the patients with COPD were hospitalized. After discharge, 14% of the patients with asthma and 50% of the patients with COPD were referred to specialized care. Conclusion: While the study patients with asthma and COPD had different health professionals providing regular care to their respiratory conditions, they both sought care before presenting to the ED. More health professionals were involved in the ED care of patients with COPD than of those with asthma. This study provided important information to support further research projects exploring ways to effectively and efficiently improve the delivery, comprehensiveness and utilization of health care services.

Introduction: The use of personal mobile devices to record patient data appears to be increasing, but remains poorly studied. We sought to determine the magnitude and purposes for which Canadian emergency physicians (EPs) and residents use their personal mobile devices (PMDs) to record patient data in the emergency department (ED). Methods: An anonymous survey was distributed to EPs and residents in the Canadian Association of Emergency Physicians (CAEP) database between 27/02/17 and 23/03/17. The survey captured demographic information and information on frequency and purpose of PMD use in the ED, whether consent was obtained, how the information was secured, and any possible implications for patient care. Participants were also asked about knowledge of, and any perceived restrictions from, current regulations regarding the use of PMDs healthcare settings. Results: The survey response rate was 23.1%. Of 415 respondents, 9 surveys were rejected for incomplete demographic data, resulting in 406 participants. A third (31.5%, 128/406, 95% CI 27.0-36.3) reported using PMDs to record patient data. Most (78.1%) reported doing so more than once a month and 7.0% reported doing so once every shift. 10.9% of participants indicated they did not obtain written or verbal consent. Reasons cited by participants for using PMDs to record patient data included a belief that doing so improves care provided by consultants (36.7%), expedites patient care (31.3%), and improves medical education (32.8%). 53.2% of participants were unaware of current regulations and 19.7% reported feeling restricted by them. Subgroup analysis suggested an increased frequency of PMD use to record patient data among younger physicians and physicians in rural settings. Conclusion: This is the first known Canadian study on the use of PMDs to record patient data in the ED. Our results suggest that this practice is common, and arises from a belief that doing so enhances patient care through better communication, efficiency, and education. Our findings also suggest current practices result in risk of both privacy and confidentiality breaches, and thus support arguments for both physician education and regulation reform.

Introduction: In the third year of medical school, students participate in a four week period called Transition to Clerkship, followed by Shadow week, where students spend one week in the discipline prior to starting clerkship. In the past, students have identified that receiving specific additional training during Shadow week would help them succeed in their rotation. To address this problem, the curriculum discussed in this paper is being developed for third year students who will be commencing clerkship in Emergency Medicine (EM). Methods: In order to assess achievement of objectives within the curriculum, questionnaires were provided to participants in the morning and afternoon of the session, as well as at the end of their rotation. Evaluative analysis is done through the Kirkpatrick program evaluation framework based on descriptive comparison of scores on the questionnaires, followed by statistical analysis with the Mann-Whitney Test (2-tailed, p=0.05) and a reflective critique. Results: Learning activities in this curriculum included: case-based learning, video critique, role play, scavenger hunt, jigsaw activity, think-pair-share, and a game-show style game. This study aims to show if, and how, providing interactive, hands-on learning sessions, which are directly relevant to clinical practice in the emergency department, positively impacted medical students beginning their clerkship in EM. Conclusion: Learners showed statistically significant positive improvement on all learning objectives of the curriculum. A reflective critique provides insight into lessons learned from delivering this curriculum and future directions for this curriculum. This learner-centered curriculum with innovative teaching methods and a considerable number of active learning strategies has encouraged the learners to take responsibility for their own learning. While this curriculum took place in the medical school, it can apply equally to learners completing their EM clerkship in a community or tertiary Emergency Department.

Introduction: Pain management is a cornerstone of emergency department (ED) practice, yet ongoing pain after ED discharge and return visits for inadequate analgesia are common. Over-the-counter (OTC) acetaminophen and nonsteroidal anti-inflammatory drugs are widely accepted first line agents for mild to moderate pain. Previous research has not investigated how patients actually consume such agents after discharge, and if they consume them synergistically and at sufficient doses for optimal analgesia. We sought to determine the proportion of patients in ongoing pain post-discharge that were utilizing analgesics as well as the type and dose of agent(s) used. Methods: Adults presenting to our ED with an acutely painful musculoskeletal complaint during research assistant hours were eligible for enrollment. After excluding non-English speakers as well as admitted, pregnant/breastfeeding, and chronic pain patients, consenting subjects completed in-person questionnaires during their ED stay and a follow-up telephone interview 2-3 days later. Results: 158 individuals were approached during the study period, of which 99 enrolled. 78 completed follow-up. At follow-up, 71 (91%) individuals experienced ongoing pain with a median score of 5 (interquartile range (IQR) 3-6) on an 11-point scale. 48 (67%) of patients still in pain consumed analgesics in the preceding 24 hours. The most commonly used agents were acetaminophen by 18 individuals (38% of analgesic users), ibuprofen by 16 (33%), and naproxen by 9 (19%). 29 respondents (60% of analgesic users) were using solely oral OTC analgesics. Only 15 (31% of analgesic users) used multiple agents concurrently, and 11 (23%) used prescription opioids. Acetaminophen was used at a median daily dose of 1500mg (IQR 1000-2000mg), much lower than that recommended for maximal analgesia (4000mg). Ibuprofen daily doses (1200mg, IQR 800-1300mg) were slightly lower than typical recommended doses (1600mg, 400mg every 6 hours). Conclusion: Only two-thirds of patients with ongoing pain at 2-3 days post-ED discharge were consuming analgesics, most commonly acetaminophen and ibuprofen. Of patients using analgesics, less than one-third used multiple agents. OTC medications are not used by most patients at doses for maximal analgesia. It may be possible to reduce pain burden and repeat-visits in discharged ED patients by optimizing the use of OTC analgesics.

Introduction: The importance of early recognition and treatment of Sepsis has been emphasized over the last several years. In an attempt to better prioritize these patients, the Canadian Triage and Acuity Scale (CTAS) revised the adult temperature modifier after 2008 to define fever as 38.0C or higher and apply SIRS criteria, appearance and immunocompromise to assign a CTAS level of 2, 3, or 4. Prior to 2008, the fever threshold was defined as 38.5C and SIRS criteria were not included. This study looks to see if these changes increased the sensitivity of the temperature modifier. Methods: This study is a retrospective cohort analysis of patients presenting with a temperature of <36.0C or >38.0C to six Edmonton-area EDs in calendar years 2008 (n=26181) and 2012 (n=51622). Outcomes of interest included the temperature modifier predicted score and the actual assigned CTAS score. Data was extracted from the HASS/iSoft EDIS database including: presenting complaint, vital signs, CTAS score, and applied CTAS modifier to generate a before and after comparison of the actual and theoretical impact of temperature modifier revisions on the CTAS score, for both time periods. Results: Applying the pre-2008 temperature modifier to the 2008 patient cohort assigned 11.5% to CTAS 2, 39.8% to CTAS 3, and 33.3% to CTAS 4. Applying the post-2008 revised temperature modifier assigned 22.2% CTAS 2, 41.9% CTAS 3, and 27.6% CTAS 4. Carrying out the same analysis on the 2012 patients pre- results were 12.4% CTAS 2, 46.4% CTAS 3, 30.2% CTAS 4; and the post results were 21% CTAS 2, 47.7% CTAS 3, and 25% CTAS 4. Differences between pre- and post-results were statistically significant (p<0.0001) in both years. The actual triage scores in 2012 were 18.7% CTAS 2 indicating the temperature modifier was not always correctly applied and 50.6% CTAS 3 as other modifiers were sometimes applied. Conclusion: There was a significant increase in sensitivity following the post 2008 revisions to the CTAS temperature modifier when applied to two large ED patient cohorts. The differences between theoretical and actual CTAS scores was less dramatic as nurses were able to apply other first order or special modifiers to assign an appropriate score. Further analysis will be carried out to determine the impact of the temperature modifier revisions on time to antibiotic and admission rates.

Introduction: Inspired by the Choosing Wisely® campaign, St. Michaels Hospital (SMH) launched an initiative to reduce unnecessary tests, treatments and procedures that may cause patient harm. Stakeholder engagement identified inappropriate ordering of urine culture & sensitivities (C&S) in the emergency department (ED) as a focus area. Inappropriate urine C&S increase workload, healthcare costs and detection of asymptomatic bacteriuria which can lead to unnecessary antibiotics. The project’s purposes were to describe the scope of inappropriately ordered urine C&S in the SMH ED and to conduct a root-cause analysis to inform future quality improvement interventions. Methods: Criteria for determining appropriateness was developed a priori using evidence-based guidelines from the University Health Network together with additional literature review. A retrospective chart review was performed on all urine C&S ordered in the ED from Jun 1 Aug 30, 2016. Each chart was reviewed for order appropriateness, demographic information and ordering provider. All inappropriate urine C&S were reviewed to identify root causes which were then grouped into common themes. A pareto chart was constructed to analyze the frequency of causes. Results: Of 425 urine C&S ordered, 75 (17.7%) were inappropriate. The top 3 reasons were: inappropriate urosepsis work-ups (53%), order processing errors (17%) and inappropriate work-ups for weakness (16%). Inappropriate urosepsis work-ups were defined as urine C&S that were ordered empirically despite there being a clear focus for infection elsewhere (i.e. cough, cellulitis) and in the absence of urinary symptoms. Order processing errors were defined as urine C&S which were sent despite there being no documented order. Inappropriate testing was more likely to occur overnight, in females and when a urine routine and microscopy was not ordered prior to C&S. 29% of patients with inappropriate C&S received antibiotics. Conclusion: 17.7% of urine C&S ordered in the SMH ED during the 3-month study period were inappropriate. The top cause was septic patients who were empirically tested despite having another source for infection identified from the outset. A possible reason for this is the recent ED emphasis on early recognition of sepsis which may encourage early use of antibiotics and empiric urine C&S. One question to resolve is whether a 17.7% overutilization rate is sufficient to make it a target for change. Interventions designed to reduce inappropriate urine C&S may inadvertently increase the number of missed cultures in patients admitted with sepsis not yet diagnosed. Next steps involve discussions between the ED, Internal Medicine, Infectious Disease and Microbiology, and patient partners to identify patient-centered change ideas and sustainable strategies. This may involve establishing guidelines for ordering urine C&S and incorporating lab services to provide oversight into urine C&S processing.

Introduction: Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). To date, there are no prospective studies describing the performance of an ED-to-OPAT clinic program. Furthermore, there are no studies that have examined physician rationale for intravenous therapy, despite this being a critical first step in the decision to refer to an OPAT program. Methods: We conducted a prospective observational cohort study of adults (age 18 years) with non-purulent SSTIs receiving parenteral therapy at two tertiary care EDs. Patients were excluded if they had purulent infections or could not provide consent. The emergency physician completed a form documenting rationale for intravenous therapy, infection size, and choice of antimicrobial agent, dose and duration. OPAT treatment failure was defined as hospitalization after a minimum of 48 hours of OPAT for: (i) worsening infection; (ii) peripheral intravenous line complications; or (iii) adverse antibiotic events. Patient satisfaction was assessed at a 14-day telephone follow up. Results: We enrolled a consecutive sample of 153 patients (mean age 60 years, 82 male (53.6%) and 38 (24.8%) with diabetes). A total of 137 patients (89.5%) attended their clinic appointment. Of the 101 patients prescribed cefazolin, 50.5% received 1000 mg and 48.5% received 2000 mg per day. There were low rates of OPAT treatment failure (3.9%). None of the adverse peripheral intravenous line events (9.8%) or adverse antibiotic events (7.2%) required hospitalization. Patients reported a high degree of satisfaction with timeliness of clinic referral (median score 9 out of 10) and overall care received (median score of 10 out of 10). The top 5 reasons given by physicians for selecting intravenous therapy were: clinical impression of severity (52.9%); failed oral antibiotic therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). Conclusion: This is the first study to identify physician rationale for the use of intravenous antibiotics for SSTIs. There was significant variability in antibiotic prescribing practices by ED physicians. This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction.

Introduction: Patients with diabetes who are in emerging adulthood, defined as the life stage between 18-29 years, have unique challenges in managing their illness and are at risk of acute complications and loss to follow-up. The studys objective was to describe emergency department (ED) utilization for hyperglycemia in emerging adults with diabetes and to characterize 30-day outcomes including return visits and admission for hyperglycemia. Methods: This was a health records review of emerging adults presenting over a one-year period to four tertiary care EDs with a diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Research personnel collected data on patient characteristics, treatment, disposition, and determined if patients returned to the ED for hyperglycemia within 30 days. Descriptive statistics were used to summarize the data where appropriate. Results: There were 185 ED encounters for hyperglycemia, representing 116 unique emerging adult patients. Mean (SD) age was 23 (3.5) years and 50.9% were female. 80 (69.0%) had known type 1 diabetes, 11 (9.5%) had type 2, and 25 (21.5%) were newly diagnosed in the ED. Of 185 visits, 98 (53.0%) resulted in hospital admission. 56 (30.3%) returned to the ED for hyperglycemia within 30 days of their initial encounter, and 21 (11.4%) resulted in admission on this subsequent visit. Conclusion: We characterized ED utilization and 30-day outcomes of emerging adults with diabetes for hyperglycemia. Future research should focus on earlier identification of those at higher risk for recurrent ED visits or admission and the efficacy of interventions to prevent these adverse outcomes.

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), carry significant morbidity for individuals even after discharge. The objective of this study was to describe the patient-important outcomes and burden of disease for emergency department (ED) patients with hyperglycemia after discharge from hospital. Methods: This was a prospective cohort study of patients 18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS over a 15-month period (Jul 2016-Oct 2017). During the ED visit, consent was obtained for a telephone follow-up call to determine patient-important outcomes. Trained research personnel collected data from medical records and completed a 14 day telephone follow-up using a standardized questionnaire to determine medication changes, missed days of school or work, and repeat admissions or visits to a healthcare provider. Descriptive statistics were used where appropriate to summarize the data. Results: Thus far, 172 patients have been enrolled in our study. Mean (SD) age is 53.9 (19.3) years and 97 (56.4%) are male. 65 (37.8%) patients were admitted from their initial ED visit. Of the 125 patients (72.7%) providing post-discharge outcomes, 75 (60.0%) required an adjustment to their diabetes medications or insulin. 21 (16.8%) patients missed days of school or work for a median (IQR) duration of 3.5 (1.3, 7.0) days. 85 (68.0%) saw another healthcare provider within a 14 day period, 45 (36.0%) saw their family physician, and 34 (27.2%) saw an internist or endocrinologist. 9 (7.2%) were seen again in the ED, 5 of these patients required admission to hospital. There was one death that occurred within the follow-up period. Conclusion: This prospective study builds on our previous retrospective work and demonstrates that visits for hyperglycemia carry a significant burden of disease beyond what may be seen in a single ED encounter. Further research will attempt to identify the factors that may be predictive of adverse outcomes in hyperglycemic patients presenting to the ED.

Introduction: Methanol intoxication is a well-recognized toxicological emergency. While most cases of significant methanol poisoning occur via ingestion, there are reports in the literature of poisoning resulting from the inhalational route. We report a series of methanol intoxications secondary to inhalational abuse of a methanol containing lacquer thinner presenting to an inner city Emergency Department. Methods: A laboratory database was searched for methanol levels > 5 mmol/L. (16mg/dL). from January 1, 2010 to December 31, 2015. A chart review was completed to determine mode of poisoning, clinical presentation, treatment, and disposition. Results: We found 35 patients who made a total of 83 emergency department (ED) visits with a methanol level > 5mmol/L. (16mg/dL). The methanol levels ranged from 5.3-39.6 mmol/L. (16.96 -126.72 mg/dL) . 73% of poisonings were secondary to inhalation of a methanol-containing lacquer thinner. The median age of these patients was 43 years, and 49% were male. The majority of patients (96%) resided in the core area. The most frequent chief complaints were substance abuse/intoxication, gastrointestinal complaints, and chest pain. 18% of patients described visual symptoms. Treatments were fomepizole only (59%), fomepizole plus hemodialysis (26%), and hemodialysis alone (2%). 49% of patients were discharged from the ED, while 28% and 23% were admitted to an intensive care unit (ICU) and an internal medicine ward respectively. There were no cases of blindness. We describe a cohort of patients who developed methanol poisoning from inhalation of a methanol containing lacquer thinner that required treatment with fomepizole and hemodialysis. While almost 1/3 of these patients were admitted to ICU, 49% were discharged from the emergency department after a course of fomepizole. The etiology of this outbreak was found to be a change in the formulation of the lacquer thinner, substituting a higher concentration of methanol for toluene. The manufacturer and a number of local retail outlets were contacted. This resulted in the product being taken off the shelves by the retail outlets, and eventually, a change in the product formulation by the manufacturer, with a resultant decrease in the methanol content. After these actions, we have not seen any additional presentations of inhalational methanol intoxication. Conclusion: We report the largest case series to date of patients who presented with methanol intoxication, requiring fomepizole and/or hemodialysis, secondary to inhalation of a methanol containing lacquer thinner. Physician advocacy regarding the etiology of this outbreak resulted in collaboration with retail outlets and subsequent action by the manufacturer. This ended the outbreak.

Introduction: Intubation is one of the highest-risk procedures performed in the ED. Few Canadian centres monitor intubation frequency, indications, methods used, success, and/or complication rates. An airway registry that tracks patient outcomes and variation in practice would be a valuable quality improvement (QI) tool. We describe the development of the BC-Airway Registry for Emergencies (BCARE) network, an emergency intubation database at two tertiary-care and one community hospital. Methods: Respiratory Therapists (RTs) are present at every intubation outside of the OR and complete a standardized post-intubation form. The airway forms were developed collaboratively with input from RTs, emergency physicians, intensivists, and anesthetists. Completed forms are collected from participating sites and data is entered into a secure online database where patient outcomes are analyzed in real-time. Results: We collected data from 737 unique intubations over 19 months with ongoing enrolment at the time of abstract submission. Mean age was 59.4 (Range 17-95, SD 17.6), Male 66.2%, intubation locations were ED (396, 53.7%), ICU (221, 30.0%), Ward (120, 16.3%). The most common indications for ED intubation were ICH/stroke (14.6%), seizure (10.9%), and sepsis (9.5%). Intubations are done by attending physicians more frequently in the ED (48.0%) compared to in the ICU (11.8%), and ward (8.6%). ED intubations were more commonly performed using video laryngoscopy (57.7%) with a smaller proportion using direct laryngoscopy (39.0%). First-pass success was 81.8% in the ED, 79.2% in the ICU, and 77.5% on the wards. Of ED intubations, 56 (14.1%) had complications and 73 (18.4%) were considered to be a difficult airway. Conclusion: The BCARE network tracks intubation performance across hospitals and is a valuable QI tool. BCARE can be used to ensure that all centres are meeting a benchmark success rate, for assessing the impact of practice changes such as pre-intubation checklists, and for implementing systematic methods to identify patients who previously had a “difficult airway.”

Introduction: Mentorship is an essential component of professional development and benefits include increased career satisfaction, scholarship, and efficiency of academic promotion. The Mastermind group, a collaborative, network-based model for mentorship has gained popularity in the business world. It comprises of a group of colleagues that provide mentorship and career advice for each other through regularly scheduled meetings. The group benefits from the combined intelligence and accumulated experience of the participants, who may be at different career stages. Methods: Academic Life in Emergency Medicine (ALiEM; www.aliem.com), a digital health professions education organization, conducted two Mastermind groups for 14 team members in 2017. The groups included all levels of academic rank from full professor to instructors, and represented 14 different medical schools in North America. Each Mastermind group completed a self-assessment summarizing their professional strengths and weaknesses, two homework assignments, and two 90-minute videoconference meetings, using a structured, moderator-facilitated format. Meetings were conducted on Google Hangouts on Air© (Google Inc.). In the initial group meeting, participants discussed their self-assessments, current projects, and career challenges. The second meeting allowed discussion of suggested professional development resources for each participant, actionable next steps, and an accountability timeline for each participant. The free, cloud-based platforms and voluntary basis for the Mastermind groups resulted in a zero-cost innovation. Results: In a post-intervention survey, the 14 participants rated the experience as 9.4/10 (response rate 100%) using a Likert scale. In a quasi-experimental analysis participants cited the need for career advice or assistance with a project as their reason for participating. Participants received specific resource recommendations during the sessions, including books, training courses, or conferences. Contacts outside the group for additional mentorship were made possible given the breadth of networks among the participants. All participants had at least one identifiable next step with accountability to the group. Overall, the participants described a synergy of energy, commitment to one anothers longitudinal success, and benefit from the diverse range of talent and expertise in the group. Many of the members discussed plans to replicate this mentorship model at their own institutions. Conclusion: Our experiences suggest that the Mastermind conceptual framework is an easily replicated, feasible, zero-cost, and effective model for professional development. Though the model was originally proposed as a method for in-person discussions, we report a more modern, online experience for professional development in our diverse, globally-distributed team.

Introduction: The Emergency Medicine Chief Resident Incubator is a year-long curriculum for chief residents that aims to provide participants with a virtual community of practice, formal administrative training, mentorship, and opportunities for scholarship. Methods: The Chief Resident Incubator was designed by Academic Life in Emergency Medicine (ALiEM; www.aliem.com) a digital health professions education organization in 2015, following a needs assessment in emergency medicine. A 12-month curriculum was created using constructivist social learning theory, with specific learning objectives that reflected 11 key administrative or professional development domains deemed important to chief residents. The topics covered included interviewing skills, contract negotiations, leadership, coaching, branding, conflict resolution, and ended with a focus on wellness and career longevity. A Core Leadership Team and Virtual Mentors were recruited to lead each annual iteration of the curriculum. The Incubator was implemented as a virtual community of practice using Slack©, a messaging and digital communication platform. Ancillary technology such as Google Hangout on Air© and Mailchimp© were used to facilitate learner engagement with the curriculum. Three in person networking events were hosted at three large emergency medicine and education conferences with special medical education guests. Outcomes include chief resident participation rates, Slack© activity, Google Hangout© web analytics, newsletter email engagement, and scholarship. We also incorporated a hidden curriculum throughout the year with multiple online publications, competitions for guest grand round presentations, and incorporation of digital technologies in medical education. Results: A total of 584 chief residents have participated over the first 3 years of the Chief Resident Incubator; this includes chief residents from over 212 residency programs across North America. Over 27,000 messages have been shared on Slack© (median 214 per week). A total of 32 Google Hangouts© have occurred over the course of the inaugural Incubator including faculty mentorship from Dr. Rob Rogers, Dr. Dara Kass and Dr. Amal Mattu. A monthly newsletter was distributed to the participants with an opening rate of 59%. Scholarship included 26 published academic blog posts, 2 open access In-Training exam prepbooks, a senior level online curriculum with 9 published modules and 3 book club reviews. Conclusion: The Chief Resident Incubator is a virtual community of practice that provides longitudinal training and mentorship for chief residents. This Incubator framework may be used to design similar professional development curricula across various health professions using an online digital platform.

Introduction: Fine art education increases the quality and quantity of observations that medical students make in both art and clinical reports. However, there are few free and accessible resources that teach art and observational skills to healthcare learners and providers. CanadiEM.org, a medical education blog, developed a new series called Spot the Diagnosis! to address this gap. The goals of the Spot the Diagnosis! series are to: 1) use art to explain medical concepts, 2) tie medical concepts to visual art, 3) hone observational skills, and 4) expose healthcare providers to art. Methods: Each piece of art for the Spot the Diagnosis! Series is selected based upon the author’s art history knowledge, resources found using an online search, and/or suggestions made by other healthcare professionals. The accompanying blog post is researched and written by a medical student in a question-and-answer style and peer-reviewed by another medical student and physician. Posts are uploaded monthly to CanadiEM.org and accessible to anyone with an internet connection. Promotion occurs on site, via email, word-of-mouth, and social media. Viewership is tracked using Google Analytics (GA). A survey for readers is planned to assess who, how, and why readers use the series, but results were not available prior to abstract submission. Results: Six Spot the Diagnosis! posts have been published, each of which begins with the selection of a piece of fine arts that showcases a potential medical diagnosis and a blog post outlining an interpretation of the work informed by observations, historical reports, and medical evidence. Each was published as a blog post on a Saturday and added to a page containing a list of all posts in the broader Arts PRN section on CanadiEM. All contained a single piece of art as the focus, 6 ± 2 (median ± IQR) questions, 638 ± 250 words, and 6 ± 3 references. The answers to questions are hidden under drop-down formatting to allow viewers to arrive at their own answers first. In the first 30 days of publication, each post in the series was viewed 1582 ± 401 times. Conclusion: The Spot the Diagnosis! series is an online educational resource published on CanadiEM.org that aims to improve learners medical knowledge and observational skills by featuring fine arts pieces with relevant question-and-answer style posts. This series fills the gap between art and medicine and has been well received by CanadiEM viewers. We look forward to analyzing responses in our survey to further understand how, why, and who uses this new and innovative resource.

Introduction: Emergency Department (ED) staff burnout correlates with psychological coping strategies used by Emergency department health professionals (EDHPs). Staff at two urban referral EDs in New Brunswick took part in a survey of burnout and coping strategies after one ED experienced an influx of new physicians and a newly renovated ED in 2011. Six years later, ED crowding and EDHP staffing problems became prevalent at both EDs. We compared levels of burnout at two urban referral EDs to determine if burnout and coping worsened over time. Methods: An anonymous survey of all EDHPs at 2 urban referral EDs was performed in 2011 and in 2017. A demographics questionnaire, the Maslach Burnout Inventory (MBI, measuring emotional exhaustion, depersonalization and personal accomplishment), and the Coping Inventory for Stressful Situations (CISS, measuring task-oriented, emotion-oriented, and avoidance-oriented coping styles) were collected. Descriptive statistics and linear regression models examined relationships over time and between the two hospitals. Results: Burnout scores were similar both at the two facilities and in 2011 (n=153) and 2017 (n=127). There were no differences between samples or EDs for important factors. Emotion-oriented coping was associated with higher levels of burnout, while task-oriented coping was inversely correlated with burnout. Experiencing professional stress was a significant predictor of emotional exhaustion, while those working longer years in their current department had higher emotional exhaustion and depersonalization. By 2017, both EDs had experienced significant nursing staff turnover (50%) compared to 2011. Conclusion: Burnout scores remained consistent after 6 years at these two urban referral EDs. Given the evidence that increased years of service is associated with increased burnout, high staff turnover rate at both EDs could explain how scores remained constant. Staff turnover may represent a way these ED systems cope in a challenging environment. In 2017, task-oriented copers continued to score lower while emotionally-oriented copers showed higher burnout risk, and experiencing professional stress remains a strong predictor of burnout.