Introduction: Safety culture is defined as the shared beliefs that an organization’s employees hold relative to workplace safety. Perceptions of workplace safety culture within paramedic services have been shown to be associated with patient and provider safety outcomes as well as safe work practices. We sought to characterize paramedics’ perceptions of the organizational safety culture across Eastern Ontario, Canada to provide important benchmarking data to evaluate future quality initiatives. Methods: This was a cross-sectional survey study conducted September 2015-January 2016 in 7 paramedic services across Eastern Ontario. We distributed an abridged version of Patterson’s previously published EMS-SAQ survey, measuring six domains of workplace safety culture, to 1,066 paramedics during continuing medical education sessions. The questions were presented for rating on a 5 point Likert scale (1=strongly agree, 5= strongly disagree) and a response of 1 or 2 was considered a ‘positive perception’ response. We present descriptive statistics and chi-square tests where appropriate. Results: We received responses from 1,041 paramedics (97.6%), with a response rate varying between 88.0% and 100% across the 8 paramedic services. One third (33.6%) were Advanced Care Paramedics (ACPs) and 39.4% of paramedics had more than 10 years’ experience. The percentage of positive responses for each domain were: Safety Climate 31.2% (95% CI 28.4-34.1), Teamwork Climate 29.3% (95% CI 26.6-32.1), Stress Recognition 56.8% (95% CI 53.8-59.8), Perceptions of Management 67.0% (95% CI 64.0-69.8), Working Conditions 42.6% (95% CI 39.6-45.7), Job Satisfaction 41.6% (95% CI 38.6-44.6). Primary care paramedics had more positive perception responses for Job Satisfaction (45% vs 35%, p=0.002), whereas ACPs had more positive perception responses for Stress Recognition (61.5% vs 54.1%, p=0.022). No association was found between gender or years of experience and a positive perception of any safety domain. Conclusion: The results provide valuable workplace safety culture data that will be used to target and evaluate needed quality improvement initiatives while also raising some awareness to paramedics of important factors related to patient and provider safety.

Introduction: Pediatric out-of-hospital cardiac arrest (OHCA) is unique in terms of epidemiology, treatment, and outcomes. There is a paucity of literature examining predictors of survival to help guide resuscitation in this population. Objective: The primary objective was to examine predictors of survival to hospital discharge. The secondary objective was to determine the probability of return of spontaneous circulation (ROSC) over the duration of resuscitation. Methods: We performed a retrospective cohort study of non-traumatic OHCA (<18 years) treated by EMS from the Toronto Regional RescuNET Epistry-Cardiac Arrest database from 2006 to 2015. We used competing risk analysis to calculate the probability of ROSC over the duration of resuscitation. We then used multivariable logistic regression to examine the role of Utstein factors and duration of resuscitation in predicting survival to hospital discharge. Candidate variables were limited to Utstein factors and duration of resuscitation due to the number of events. We used area under the receiver operating characteristic (ROC) curve (AUC) to determine the predictive ability of our logistic regression model. Results: A total of 658 patients met inclusion criteria. Survival to discharge was 10.2% with 70.1% of those children having a good neurologic outcome. The overall median time to ROSC was 23.9 min. (IQR 15.0,36.7). However, the median time to ROSC for survivors was significantly shorter than the time to ROSC for patients who died in hospital (15.9 (IQR 10.6 to 22.8) vs. 33.2 (IQR 22.0 to 48.6); P value <0.001). There was a decrease in the odds of survival of 14% per minute during the first 25 minutes of cardiac arrest. Older age (OR 0.9, 95% CI 0.86,0.99), and longer duration of resuscitation (OR 0.9, 95% CI 0.88,0.93) were associated with worse outcome while initial shockable rhythm (OR 5.8, 95% CI 2.0,16.5), and witnessed arrests (OR 2.4, 95% CI 1.10,5.30) were associated with improved patient outcome. The AUC for the Utstein factors was fair (0.77). Including duration of resuscitation improved the discrimination of the model to 0.85. Conclusion: Inclusion of duration of resuscitation improved the performance of our model compared to Utstein factors alone. However, our results suggest there are a number of other important factors for predicting patient outcome from pediatric OHCA.

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two London, Canada tertiary care Emergency Departments (ED) between April 2014 and July 2016 to improve patient care by increasing value and reducing waste. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards, and a novel initial assessment process. Offload delays are associated with longer hospital length of stay and delayed admission, and may increase morbidity and mortality. Delays also result in fewer circulating ambulances in the community. CIHI sets a benchmark of 30 minutes as an acceptable offload target. It is possible that EDST may have impacted offload times. Methods: Middlesex-London EMS provided offload times. Data was collected from London Health Sciences Centre including daily ED visit volumes, ED occupancy, offload nursing hours, and site variation. A binomial logistic regression analysis was performed to determine the impact of interventions and confounding variables on the proportion of patients meeting CIHI benchmark. A chi-square analysis was done comparing proportion of patients meeting the benchmark in the first 3 months versus the last 3 months to identify overall impact of EDST to date. Results: Increased offload nursing hours had a positive impact (p<0.001) on the proportion of offload times meeting the CIHI benchmark while increased ED visit volume and hospital inpatient volume had a significant negative impact (p<0.001). At both ED sites, the proportion of patients meeting the offload target ranged from 58-83% over the timeframe. There was a significant increase in the proportion of patients meeting the benchmark from the first quarter to the last quarter (69.6% vs 75.0%; 95% CI 3.45% to 7.38%, p=0.000). Specific interventions had varying degrees of impact on offload times. Conclusion: The proportion of patients meeting the benchmark offload time varied over the study timeframe but significantly increased with EDST implementation. Offload times are one of many outcomes we aim to improve with EDST and it remains an ongoing process as new interventions continue to be implemented. Once transformation is complete, future studies will focus on the impact of EDST on all ED flow metrics, and patient and provider satisfaction.

Introduction: Domestic violence (DV) rates in smaller cities been reported to be some of the highest in Canada. It is highly likely that emergency department staff will come across victims of intimate partner violence (IPV) in their daily practice. The purpose of this study is to better understand current practices for detecting IPV as we are currently uncertain whether patients are assessed for IPV and what the current documentation practices are. Methods: A standardized retrospective chart review, following principles outlined by Gilbert et al. 1996, was completed by two researchers to capture domestic violence documentation rates in patients presenting to the ED between January and April 2015 with injuries that may have been caused by IPV. To assess self-reported documentation/questioning practices, a cross-sectional online survey was distributed to ED staff via staff email lists three times between July and October 2016, with a response rate of 45.9% (n=55). The primary outcome was DV field usage. Secondary outcomes included documentation in patient charts and current questioning habits. Results: Overall, we found documentation in 4.64% of all included patient charts (n=366). No documentation was noted in the DV field. 52.4% patients with deliberate injuries had no documentation of assailant identity. With regards to self reported documentation practices, 16.4% of ED staff never questioned female patients about intimate partner violence, 83.6% asked when thought appropriate, and none asked routinely. None of the staff used a structured screening tool. 60% of ED staff documented their questioning but 92.7% did not use the DV-field for documentation. 58.2% of ED staff could not identify the DV field and 45.5% of respondents did not know how to interpret the DV field if positive. Conclusion: Our findings suggest that the current documentation tool (DV-field) is not being utilized. Furthermore, low rates of IPV documentation, and potentially questioning, in high risk patients indicates that there is need to improve current practises.

Introduction: Intra-articular steroid injection (IASI) is commonly used in the emergency department for management of osteoarthritis (OA) symptoms. Hip IASI carries risks, such as avascular necrosis, and there is currently no reliable way to predict long-term response of a patient’s OA to IASI. Ultrasound (US) conveniently assesses for active arthropathy by detecting effusion-synovitis, and x-ray (XR) is useful for visualizing bone-related changes. We investigated the extent that a response to hip IASI could be predicted from baseline OA patient clinical and physical features alongside US and XR imaging features. Methods: 97 consenting patients with symptomatic hip OA presenting for hip IASI were evaluated at baseline (XR and US) and again 8-weeks after IASI (US only). Self-reported pain (WOMAC), hip range of motion (ROM) were measured at baseline and follow up. On US images we quantified joint effusion and synovial thickening, i.e., “effusion-synovitis”, by the bone-capsule distance (BCD) at the apex of the femoral head from outer femoral cortex to outer synovium. On XR, we measured minimum joint space width (cm) and Kellgren-Lawrence (K-L) Grade for osteophytes and sclerotic changes. Results: In our 97 patients (43 female) aged 28-87 years (mean 59+/-13 years, K-L grades averaged 2.5+/-1.5, and US BCD averaged 5.9+/-2.0 mm. We performed multiple linear regression using age, sex, BMI, ROM of hip flexion, US BCD, radiographic joint space width and K-L grade against the dependent variable, change in WOMAC pain subscore (R=0.587, P=0.002). We compared the response predicted by this model to the actual change in WOMAC pain. At a threshold value of -20% for minimal clinically important difference, 35/97 patients were responders, and a 2x2 table gave 67% overall model predictive accuracy, 61% sensitivity, and 71% specificity. Likelihood ratio for a positive response (LR+) was 2.13. Conclusion: Combining radiographic information on structural damage, US information on active arthropathy, and demographics correctly predicted about two-thirds of the patients that would benefit from IASI after 8 weeks. A patient with hip OA that met our model criteria was more than twice as likely to respond to IASI. With further model refinement, effective, personalized evidence-based management of symptomatic hip OA is possible using XR and hip US, which could both be performed during an ER visit.

Introduction: In Canada, family physicians (FPs) provide the majority of early pregnancy care. To receive a same day US, most patients will be sent to the emergency department (ED). FPs are starting to use point of care ultrasound (POCUS) for a variety of indications. The FaMOUS course was modeled after the Canadian Emergency Ultrasound Society (CEUS) ED Echo (EDE) curriculum and adapted with permission for FPs. The objective of this study was to assess the indications for POCUS use in early pregnancy and determine the diagnostic accuracy of POCUS performed by FPs following FaMOUS certification to detect intrauterine pregnancy (IUP) and fetal cardiac activity (FCA). Methods: This was a prospective, observational study conducted in 3 FP clinics from November 2015 to June 2016. Pregnant women <20 weeks gestational age who underwent a focused, transabdominal POCUS by a FaMOUS-certified FP using a handheld GE VScan were enrolled. FPs documented the presence or absence of IUP and FCA. The reference standard was radiologist-interpreted US performed after the FP POCUS. FPs were surveyed to assess provider confidence using POCUS and perceived impact on clinical decision-making. Results: Of 253 eligible patients, 56 (22.1%) underwent POCUS. Of these, 50 (89.3%) had a radiologist-interpreted US following the office-based FP visit. POCUS was used for the following indications: 11 (19.6%) had vaginal bleeding, 5 (8.9%) had abdominal pain, 7 (12.5%) had both vaginal bleeding and abdominal pain, and the indication for 33 (58.9%) patients was unclear. All patients had a documented IUP, resulting in a sensitivity of 94.0% (95% CI: 83.5%, 98.5%) and 100% positive predictive value. FCA resulted in sensitivity of 82.9% (95% CI: 69.2, 92.4%) and specificity of 100% (95% CI: 29.2%, 100.0%). When surveyed, 100% of FPs were confident performing POCUS and reported POCUS had an overall positive impact on clinical practice. 75% agreed the use of POCUS decreased the need for urgent radiologist-interpreted US. Conclusion: Following a certification process modeled after the CEUS EDE curriculum, FPs used POCUS for both CEUS-defined indications and indications that were unclear. FPs trained in early pregnancy POCUS demonstrated excellent diagnostic accuracy identifying IUP and FCA. Future study should assess the clinical impact of office-based POCUS, including whether its use results in decreased ED visits for this patient population.

Introduction: Discharge from the Emergency Department (ED) is a high-risk period for communication failures. Clear verbal and written discharge instructions at patient-level health literacy are fundamental to a safe discharge process. As part of a hospital-wide quality initiative to measure and improve discharge processes, and in response to patient feedback, the St. Michael’s Hospital ED and patient advisors co-designed and implemented patient-centred discharge handouts. Methods: The design and implementation of discharge handouts was based on a collaborative and iterative approach, including stakeholder engagement and patient co-design. Discharge topics were based on the 10 most common historical ED diagnoses. ED patient advisors and the hospital’s plain language review team co-designed and edited materials for readability and comprehension. Process mapping of ED workflow identified opportunities for interventions. Multidisciplinary ED stakeholders co-led implementation, including staff education, training and huddles for feedback. Patient telephone surveys to every 25th patient presenting to the ED meeting the study inclusion criteria (16 years of age or older, directly discharged from the ED, speaks English, has a valid telephone number, and has capacity to consent) were conducted both pre- (June-Sept 2016) and post- (Oct-Dec 2016) implementation. Results: Stakeholder engagement and co-design took place over 10 months. Education was provided across one MD staff meeting, four RN inservices, and at monthly learner orientation. 44846 patients presented to the ED and 25600 met the study inclusion criteria. 935 surveys (response rate=97%; declined n=30) were completed to date. Pre-implementation (n=467), 9.2% (n=43) of patients received printed discharge materials and 71% (n=330) understood symptoms to look for after leaving the ED. Post-implementation (n=468), 44% (n=207) of patients received printed discharge materials with 97% (n=200) finding the handouts helpful and 82% (n=385) understanding symptoms to look for after leaving the ED. Conclusion: Through the introduction of patient co-designed and patient-centred discharge handouts, we have found a marked improvement in patient understanding, and consequently safer discharge practices. Future efforts will focus on optimizing discharge communication, both verbal and written, tailored to individual patient preferences.

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods: This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primary outcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results: A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71±15, 67±12, 67±13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA2DS2-VASc score was 2.6±1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA2DS2-VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p<0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p<0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion: Use of a simple OAC-prescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated.

Introduction: How is “administer a fluid bolus” interpreted by paramedics? There is no existing literature describing this practice in the prehospital setting. Paramedic medical directives authorize the administration of Normal Saline 20 ml/kg to hypotensive patients (systolic BP <90). Anecdotally, auditors of Ambulance Call Reports (ACRs) and paramedics report this amount of fluid is rarely administered. The aim of this study was to determine the amount and rate of IV fluid administered by Advanced Care (ACP) and Primary Care (PCP) paramedics when they give an IV ‘fluid bolus’ during an ambulance call. Methods: We conducted a retrospective analysis of iMedic platform, electronic, ACRs (January 01, 2015 to June 30, 2015) from 8 municipal paramedic services that serve an urban and rural population of 1.4 million. ACRs containing a procedure code 351 (intravenous fluid bolus) were identified. A stratified, random sample of 20 cases per paramedic category (ACP and PCP) from each service was generated using a random number table. ACRs were manually searched, data abstracted onto spread sheets, and the results analyzed using descriptive statistics (Wizard ver 1.8.16 for Mac). Results: The initial sample was 220 cases. 25 were excluded for incomplete documentation, leaving 195 cases (ACP 59, PCP 136) for analysis. The mean IV fluid bolus volume delivered was: ACP 414.8 ml (95%CI: 344.2, 485.4), PCP 242.3 ml (95%CI: 210.9, 274.5). The mean rate of infusion was: ACP 22.7 ml/min (95%CI: 17.6, 27.8) PCP 15.7 ml/min (95%CI 13.2,18.1). Percentage of cases where >250 ml was infused: ACP 74.6%, PCP 44.1%. Percentage of cases where at least 10 ml/kg of fluid was given: ACP 17.0%, PCP 2.9%. Percentage of cases reaching the maximum 20 ml/kg of fluid: ACP 0.5%, PCP 0%. IV cannula size: 18G-ACP 57.4%, PCP 33.3%; 20G ACP 37.0%, PCP 56.8; 22G ACP 0.6%, PCP 9.8%. Conclusion: Paramedics rarely gave the amount of IV fluid they were authorized to give to hypotensive patients. On average, Advanced Care Paramedics administered significantly more fluid and gave it significantly faster than Primary Care Paramedics. ACPs were more likely than PCPs to use 18G cannulas and rarely used 22G cannulas whereas PCPs preferred to use 20G IV cannulas. Further training is required to clarify and improve the paramedic practice of IV bolus administration.

Introduction: Best practice guidelines recommend that at least two sets of blood cultures be sent when blood cultures are required. However, high rates of solitary blood cultures are still common in the emergency department. The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the lab on patients ultimately discharged from our emergency department. Methods: This was a multi-centre, multi-phase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts. Results: The baseline rate of solitary sets of blood cultures was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a forcing function with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (P=0.071). However, the forcing function produced a statistically significant improvement (P < 0.0005), which was maintained for 6 months. Conclusion: The combination of a brief education-based intervention and a computerized forcing function was more effective than education alone in reducing solitary blood culture collection in our emergency department in this time series study. Forcing functions can be a powerful tool in modifying behaviours and processes in the clinical setting.

Introduction: Asthma is a chronic condition and exacerbations are a common reason for emergency department (ED) presentations across Canada. The objective of this study was to characterize and describe acute asthma presentations over a five-year period. Methods: Administrative health data for Alberta from 2011-2015 was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) acute asthma (ICD-10-CA: J45) ED presentations. All presentations to an Alberta ED with a primary or secondary diagnosis of acute asthma were eligible for inclusion. Presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1 were excluded. Data from NACRS were linked with a provincial diagnostic imaging database. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, a total of 51,269 (~10,000/year) acute asthma presentations were made by 34,481 patients (~0.3 presentations per patient per year). The median age was 35 years (IQR: 25, 49 years) and more patients were female (57.2%). Few patients arrived to the ED by ambulance (6.5%) and the most frequent CTAS score was 3 (43.5%). The majority of these patients (77%) had a primary diagnosis of asthma in the ED. Differences were explored between those with a primary asthma diagnosis and those with a secondary diagnosis (e.g., ambulance arrival, length of stay, hospital admission, etc.). Although differences were statistically significant, no clinically relevant differences were identified. Patients with asthma most frequently had a co-diagnosis of acute upper respiratory infection (6.2%); other co-diagnoses included bronchitis (4.7%), pneumonia (3.7%), heart failure (0.18%), pulmonary embolism (0.15%), and pneumothorax (0.03%). For 39.3% of patients, ED management included chest x-ray. The majority of patients were discharged from the ED (92.2%) following a median length of stay of 2.2 hours (IQR: 1.2, 3.8 hours). Conclusion: Acute asthma remains an important ED presentation in Alberta and the absolute frequency of presentations has remained relatively stable over the past five years. Frequency of chest x-ray ordering is high and represents a target for future interventions to reduce ionizing radiation exposure, improve patient flow and reduce healthcare costs.

Introduction: Older patients are a high-risk population in the Emergency Department (ED) for poor outcomes after ED visit, including return presentation and hospital admission. Little is known however about outcomes in older patients identified as “low acuity” by triage. We aim to describe the characteristics, ED workup, disposition, and 14-day outcomes of ED patients 65 years and up who are triaged as low acuity and compare them to a younger cohort. Methods: This health records review was done in a Canadian tertiary care ED. Included patients received a Canadian Triage Acuity score (CTAS) of 4 or 5 and were either 65 years and up (“older” group), or 40-55 years (controls). Data collected included patient demographics, tests and services involved in ED, and disposition. Return ED visit and hospital admission rates at 14 days were tracked. Data were analyzed descriptively and chi-square testing conducted to assess for differences (p < 0.05) between groups. A pre-planned stratified analysis of patients 65-74 years, 75-84, and 85 and older was conducted. Results: 350 patients (mean age 76.5, 56.6% female) were included in the older group and 150 in the control group (mean age 47.3, 55.3% female). Most patients presented with musculoskeletal or skin complaints (older cohort: 28.6% extremity pain/injury, 10% rash, 8.9% laceration, versus control 30% extremity pain/injury, 14.7% rash, 14.0% laceration) and were triaged to the ambulatory care area (88.6% elderly, 99.3% control). Older patients were significantly more likely than younger controls to be admitted on index visit (5.0% vs 0.3% admit rate, p=0.016). They had a trend towards increased re-presentation rates within 14 days (13.7% vs 8.7% control, p=0.11) and were more likely to be admitted on re-presentation (4.0% vs 0.7%, p=0.045). In sub-group analysis, very elderly patients (85 years and up, n=79) were more likely to be admitted (8.9%, p=0.003). Conclusion: Patients 65 years of age and older who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients 85 years and up are the primary drivers of this higher admit rate. This study characterizes “low acuity” elders presenting to ED and indicates these patients are high risk for re-presentation and admission within 14 days.

Introduction: Altered mental status (AMS) and cognitive impairment are common problems in elderly patients presenting to the emergency department (ED). The primary objective of this study was to test the diagnostic accuracy of the Ottawa 3DY (O3DY) screening tool for the detection of AMS in the ED. Methods: This was a prospective cohort study conducted at an inner city, academic ED with an annual census of 85,000 visits. Study investigators and trained research assistants screened and approached a convenience sample of patients for informed written consent. Patients completed the O3DY, Short Blessed Test (SBT) and Mini-Mental Status Exam (MMSE). Descriptive statistics using counts, medians, means and interquartile ranges (IQR) were calculated. Sensitivity and specificity of the O3DY compared to the MMSE were calculated in STATA (version 11.2). Results: We screened 163 patients for inclusion, 150 were eligible to participate, and 116 patients were enrolled in the final study. The median age of participants was 81 (IQR 77-85), 44.8% were female, and the most common pre-existing comorbidity was hypertension. The median ED LOS at the time of O3DY completion was 1:40 (IQR 1:34-1:46). Characteristics of patients eligible, yet who declined to participate, were similar to the study population. The sensitivity of the O3DY for AMS was 71.4% (95%CI 47.8-95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were moderate. Conclusion: In a cohort of geriatric patients presenting to an inner-city, academic ED the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of AMS.

Introduction: Cycling as a form of active transportation is popular in many urban communities. However, little is known about the prevalence and circumstances of cycling injuries, particularly injuries resulting from single bicycle crashes which are not recorded in road trauma surveillance systems based on police crash reports. This study aimed to examine the profile and circumstances of cycling injuries seen in an urban emergency department (ED). Methods: This was a cross-sectional historical chart review study. All injured patients attending our ED are electronically flagged according to mechanism of injury. We reviewed the medical charts of all ED visits in 2015 that were flagged as “Cyclist Injury” or “Fall” to identify all cyclists who were injured while travelling on public roads (including sidewalks). Off road injuries were excluded. Results: In 2015, a total of 6450 ED presentations were flagged as cyclist injury (n=694) or fall (n=5756), and 667 cycling injuries met our inclusion criteria. Of these, 73 (11%) were admitted to hospital. The most common mechanisms of injury were fall from bicycle (51%), crash into stationary object (16%), and collisions with moving motor vehicles (25%). Potential contributing factors included alcohol or drug impairment (11%), road hazards (9%), avoidance manoeuvre (5%) and dooring (3%), although the cause of the crash was generally poorly documented in the medical charts. The most common injured body regions were upper extremity (55%) followed by head and neck (34%). Most injuries were abrasions/lacerations and fractures. Conclusion: Two thirds of cyclist injuries in this series were caused by single bicycle incidents, events not captured in official road trauma statistics which are based on police crash reports. The large majority of injured cyclists were treated and released from the ED. In most cases, the cause of the crash was poorly documented. This data highlights the limitations of using police crash reports or hospital admission records for road trauma surveillance and the significant knowledge gap in our understanding of causative factors leading to cycling injuries.

Introduction: Recruitment and retention of healthcare staff are difficult in rural communities. Poor quality of work life (QWL) may be an underling factor as rural healthcare professionals are often isolated and work with limited resources. However, QWL data on rural emergency (ED) staff is limited. We assessed QWL among nurses and physicians as part of an ongoing study on ED care in Québec. Methods: We selected EDs offering 24/7 medical coverage, with hospitalization beds, in rural or small towns (Stats Canada definition). Of Québec’s 26 rural EDs, 23 (88%) agreed to participate. The online Quality of Work Life Systemic Inventory (QWLSI, with 1 item per 34 “life domains”), was sent to all non-locum ED nurses and physicians (about 500 potential participants). The QWLSI is used for comparing QWL scores to those of a large international database. We present overall and subscale QWL scores as percentiles (PCTL) of scores in the large database, and comparisons of nurses’ and physicians’ scores (t test). Results: Thirty-three physicians and 84 nurses participated. Mean age was 39.8 years (SD=10.1): physicians=37 (7.7) and nurses=40.9 (10.7). Overall QWL scores for all were in the 32nd PCTL, i.e. low. Nurses were in the 28th PCTL and physicians in the 44nd (p>0.05). For both groups, QWL was below the 25th PCTL i.e. very low, for “sharing workload during absence of an employee”, “working equipment”, “flexibility of work schedule”, “impact of working hours on health”, “possibility of being absent for familial reasons”, “relations with employees”. The groups differed (p<0.05) on only two subscales: remuneration and career path. For remuneration, scores were similar on fringe benefits (nurses 22nd PCTL, physicians 32nd) and income security (nurses 72nd, physicians 74th), but differed on income level (nurses 74th, physicians 93rd). The groups differed on all 3 career path items: advancement possibilities (nurses 53th, physicians 91st), possibilities for transfer (nurses 51nd, physicians 84th) and continuing education (nurses 18th, physicians 49th). Conclusion: Overall QWL among rural ED staff is poor. Groups had similar QWL scores except on career path, with physicians perceiving better long-term prospects. Given difficulties in rural recruitment and retention, these findings suggest that QWL should be assessed in rural and urban EDs nationwide.

Introduction: When patients transition from long term care (LTC) to emergency departments (ED), communication among clinicians in different settings is often poor. We pilot tested a transfer form to facilitate communications of handover information among LTCs, emergency medical services (EMS), and EDs regarding LTC residents transitioning to and from the ED. We interpret implementation challenges in light of the “theoretical domains” implementation framework in order to produce lessons for future healthcare communication interventions. Methods: We provided setting specific training and a user guide to 13 participating sites, collected 90 forms to assess completion rates, and assessed perspectives on the form from 266 surveys of healthcare providers. Throughout the study, staff kept detailed notes on implementation of the form. We retrospectively categorized implementation challenges reported by survey respondents, and/or recorded in staff implementation notes, according to the theoretical domains framework. Results: The LTC patient transfer forms were used in 36.4% of transitions (90/247), and were completed most often by staff in the LTC (57/90, 63%). Survey results indicated that ED and EMS staff felt the information on the form was useful to them, although they rarely completed their sections of the form. Implementation challenges included low awareness/recognition of the form among healthcare providers, belief that the form distracted from patient care, lack of time for form completion, negative reinforcement for LTC staff (who saw little return for the time they invested in completing the form), and mistrust among clinicians who work in different settings. Conclusion: Future efforts to improve healthcare communications must be acceptable for all clinicians. Innovation should balance the workload required among sites/clinicians and the benefits that the intervention offers to sites/clinicians should be explicitly tracked and reported. For this intervention, more effort should be made to inform LTC sites that the transfer information they provide is useful for EMS and ED clinicians. Moreover, gaps in perspectives and lack of trust among clinicians who work in different settings must be recognized and addressed in any multi-site communication intervention.

Introduction: Within Alberta, 30% of patients presenting to emergency with minor traumatic brain injury (mTBI) will receive a CT scan before being sent home, regardless of whether it was clinically indicated. Choosing Wisely (CW) Canada recommends using validated clinical decision support to determine whether a CT scan is necessary for patients presenting with a mTBI. In order to provide patients with information on the risks and benefits of CT scans in mTBI and to encourage discussions between patients and their doctor, the Emergency StrategicClinical Network (ESCN) designed a patient focused information visualization on CT scans for head injuries. Methods: The ESCN, Physician Learning Program and CW Alberta partnered with the Mount Royal University Department of Information Design to develop a patient information visualization (infographic) intervention. Students spent a semester developing these infographics on Choosing Wisely recommendations, which were then presented to stakeholders. A student was then selected to develop a final design. Refinement of the design took place in consultation with clinical experts and tested in two patient focus groups. The final design was evaluated against the International Patient Decision Aid Standards checklist. The infographic was posted in 2 local emergency department waiting rooms. A survey was administered to any patients in the waiting room when volunteers were available. The survey was designed to evaluate whether the tool influenced patient beliefs about the risks and benefits of CT scans, and their willingness to engage in a discussion with their doctor. Results: In a 26 day period, 90 patients consented and completed the survey. Before reading the infographic, 33% of patients thought that after a head injury a CT was always a good idea and 63% thought it was sometimes a good idea. 82% and 91% of patients stated the poster helped them understand the indications and risks of CT imaging for mTBI. After viewing the poster, only 15% of patients felt that a CT was always a good idea after a mTBI. Conclusion: The mTBI patient infographic significantly changed patient perceptions regarding the need for CT scans in the setting of mTBI. This study demonstrates that targeted patient education materials can help support CW recommendations.

Introduction: Appropriate pain management relies on the use of valid, reliable and age-appropriate tools that are validated in the setting in which they are intended to be used. The aim of the study was to assess the psychometric properties of pain scales commonly used in children presenting to the pediatric emergency department (PED) with an acute musculoskeletal injury. Methods: Convergent validity was assessed by determining the Spearman’s correlations and the agreement using the Bland-Altman method between the Visual Analogue Scale (VAS), Faces Pain Scale-Revised (FPS-R) and Color Analogue Scale (CAS). Responsiveness to change was determined by performing the Wilcoxon signed-rank test between the pre-post analgesia mean scores. Reliability of the scales was estimated using relative (Spearman’s correlation, Intraclass Correlation Coefficient) and absolute indices (Coefficient of Reliability). Results: A total of 495 participants was included in the analyses. Mean age was 11.9 ±2.7 years and participants were mainly boys (55.3%). Correlation between each pair of scales was 0.79 (VAS/FPS-R), 0.92 (VAS/CAS) and 0.81 (CAS/FPS-R). Limits of agreement (80%CI) were -2.71 to 1.27 (VAS/FPS-R), -1.13 to 1.15 (VAS/CAS) and -1.45 to 2.61 (CAS/FPS-R). Responsiveness to change was demonstrated by significant differences in mean pain scores, among the three scales, between pre- and post-medication administration (p<0.0001). ICC and CR estimates suggested acceptable reliability for the three scales at 0.79 and ±1.49 for VAS, 0.82 and ±1.35 for CAS, and 0.76 and ±1.84 for FPS-R. Conclusion: The scales demonstrated good psychometric properties with a large sample of children with acute pain in the PED. The VAS and CAS showed a stronger convergent validity, while FPS-R was not in agreement with the other scales. Clinically, VAS and CAS scales can be used interchangeably to assess pain intensity of children with acute pain.

Introduction: Computed tomographic pulmonary angiograms (CTPAs) are often ordered to evaluate pulmonary embolism (PE) in the emergency department (ED). However, these studies often yield alternative diagnoses and report incidental findings that lead to additional unnecessary investigations. Our objective was to assess the prevalence and significance of such findings and their implications in patient management. Methods: This is a retrospective cohort study of adults presenting to two tertiary care EDs in 2015, being evaluated with CTPA for PE. Data was extracted by two reviewers from electronic CT records with inter-rater reliability reported using kappa statistic. We measured prevalence of PE, incidental findings and alternative diagnoses with data reported as mean and standard deviation (SD). Univariate analyses were performed with t-test for continuous variables and Mantel-Haenszel test for categorical variables. A sample size of 770 was calculated based on an expected difference in prevalence between significant and non-significant incidental findings of 80% (α=5%, Power=90%). Results: A total of 1629 studies were included (mean 62 yrs, SD 16.7, 56.9% female, median CTAS score 2, 45.2% admitted). PE was found in 233 (14.3%) patients. 173 (10.6%) studies had a finding of an alternative diagnosis, the majority being pulmonary infiltrates (n=130, 75.1%). In patients who underwent both CTPA and chest x-ray (CXR), CXRs alone would have led to the same alternative diagnosis in 116 (77.1%) patients. A total of 223 (13.6%) patients had an incidental finding; the majority included pulmonary nodules (n=83, 37.2%) and adenopathy (n=26, 11.6%). Only 26 (17.1%) incidental findings were significant; most common included pulmonary nodules (n=6, 3.9%) and masses (n=7, 4.6%) that lead to newly identified and biopsied lung cancer diagnoses. Incidental findings led to an additional 301 follow-up CTs with a yield of significant result of 9.2% (n=48 CTs). Conclusion: Chest CTs ordered in the ED for clinical suspicion of PE is equally as likely to identify alternative diagnoses or incidental findings as PE. The majority of incidental findings are non-significant and result in an increased use of CT. CXRs should routinely be ordered prior to further investigation for PE with chest CT to reduce unnecessary testing and thus time and cost to the system.

Introduction: Multiple studies since the ‘90’s demonstrate that ED staff fail to identify delirium in up to 75% of older patients. Those patients who are discharged have a 3-fold increased mortality. Methods: We iteratively developed a 14-item interprofessional tool with 4 clinical vignettes to assess comfort, knowledge and ability to identify delirium among medical students, EM residents, staff MDs and RNs. We conducted a prospective observational study using modified Dillman survey methodology. Surveys were sent on paper to residents and nurses and online to medical students and staff MDs. Results: Our response rate was 68% (38/56) for residents, 80%(16/20) for RNs; but only 37%(13/35) for staff MDs and 13%(139/1036) for medical students. Comfort with identifying delirium increased with level of medical training; 38/139(27%) 1st-4th year medical students (MS1-MS4); 25/38(66%) 1st-5th year residents (R1-R5); and 12/13(92%) staff physicians reported being comfortable (χ2=34.7, df=2, p<0.001). MS1-MS2 were the least comfortable, with only 5/82(6%) reporting comfort, increasing to 33/57(58%) among MS3-MS4 (χ2=44.9, df=1, p<0.001). A greater proportion of R4-R5 who completed a geriatric emergency medicine (Geri-EM) curriculum reported comfort, 11/12(92%) compared to 14/26(54%) of R1-R3 (χ2=19.2, df=1, p<0.05). Only 5/16(31%) nurses reported being comfortable with identifying delirium. Ability to identify all 4 clinical vignettes correctly was higher among MS3-MS4 than MS1-MS2 (32/57(56%) vs. 30/82(37%), χ2=5.2, df=1, p<0.05). There was no difference between respondents from different levels of medical training (62/139(45%) MS1-MS4, 21/38(55%) R1-R5 and 6/13(46%) staff MDs, χ2=1.4, df=2 p=0.52). There was no effect of Geri-EM completion on perfect vignette scores (6/12(50%) R4-R5 vs. 15/26(58%) R1-R3, χ2=0.20, df=1, p=0.66). There was a trend towards a lower proportion of nurses who identified all 4 clinical vignettes correctly compared to physicians (4/16(25%) vs. 27/51(53%), χ2=3.82, df=1, p=0.051). Conclusion: Our tool may be useful for assessing comfort and knowledge of delirium among ED physicians and nurses. Completion of the Geri-EM curriculum was associated with increased comfort with detecting delirium but not knowledge. Future studies should assess current ED delirium comfort and knowledge at different levels of training; between professions and examine differences nationwide.