Introduction: The CJEM Social Media Team was created in 2014 to assist the journal with the dissemination of its research online. It consists of two Social Media Editors (Junior and Senior) and a team of volunteer medical students and residents to assist their work. Collaborative promotional agreements were developed to promote CJEM articles on the Skeptics’ Guide to Emergency Medicine (SGEM) podcast through the ‘Hot off the Press’ (HOP) series and the CanadiEM blog through an infographic series. Methods:CJEM papers were selected for promotion by the Team based on their perceived interest to the online community of emergency physicians. Altmetric scores, which are a measure of online dissemination derived from a weighted algorithm of social media metrics, were collated for articles promoted using the SGEM HOP or CanadiEM blogs. A control group was created using the articles with the top two Altmetric scores in each CJEM issue in 2015 and 2016. Erratum, Letters, and articles written by the social media editors were excluded from the control groups. The success of the social media promotion was quantified through the measurement of Altmetric scores as of January 1, 2017. Unpaired two-tailed t-tests with unequal variance were used to test for significant differences. Results: 106 and 82 eligible articles were published in 2015 and 2016, respectively. Four articles in 2015 and two articles in 2016 were excluded from the control groups because they were written by the social media editors. SGEM HOP podcasts promoted one article in 2015 and five articles in 2016. CanadiEM infographics promoted three articles in 2015 and eight articles in 2016. No articles were promoted in both series. The average Altmetric score was higher for SGEM HOP (61.0) than CanadiEM Infographics (31.5, p<0.04), 2015 controls (15.8, p<0.01), and 2016 controls (13.6, p<0.01). The average Altmetric score for CanadiEM Infographics was higher than 2015 controls (p<0.04) and 2016 controls (p<0.02). There was no significant difference between the control groups. Conclusion: The results suggest that collaborating with established social media websites to promote CJEM articles using podcasts and infographics increases their social media dissemination. Given the nonrandomized design of these results, causative conclusions cannot be drawn. A randomized study of the impact of social media promotion on readership is underway.

Introduction: Syncope accounts for 1-3% of Emergency Department (ED) visits. Previous studies have reported overuse of computed tomography (CT) of the head among syncope patients. Professional organizations including Choosing Wisely have recommended against its use in the absence of high-risk features. However, a review of CT head use among syncope patients and its diagnostic yield has not been previously reported. Methods: We conducted a systematic review using EMBASE, Medline, and Cochrane databases from inception to August 2016. We included studies involving adult syncope patients that reported CT head use and its diagnostic yield during acute management by a two-step process: first title/abstract review and then full-text review of selected articles. We excluded case reports, narrative reviews and those involving children. We collected the proportion of patients who had CT head performed, and its diagnostic yield. Outcomes included identification of acute intracranial conditions (hemorrhage, mass or infarct) that require further management. Two reviewers independently abstracted the data and discrepancies were resolved by consensus. We calculated inter-observer reliability for inclusion in the systematic review using kappa values. We performed meta-analysis for diagnostic yield of the CT head. Results: Fifteen studies with 2,802 syncope patients in four sub-groups (proportion of patients among whom CT head was performed and its yield in ED and inpatient settings; studies that reported only the yield among those with CT head performed; and the use and yield among syncope patients ≥65 years old) were included. The inter-observer agreement for inclusion of final articles for meta-analysis was κ=0.925 [95% CI: 0.861-0.990]. Seven ED studies (n=1,261) reported 55.7% patients (95% CI: 32.1-78.0%) had head CT performed with a yield of 4.0% (95% CI: 2.7-5.6%); 5 studies with 1138 hospitalized patients reported that 38.6% (95% CI: 20.4-58.6%) had head CT with a yield of 1.1% (95% CI: 0.4-2.2%). The yield among studies that report only outcomes for CT head was 2.3% and the yield among patients’ ≥65 years was 7.7%. Conclusion: Our review found that a very high proportion of syncope patients had CT head performed during acute management with a very low diagnostic yield. The yield is higher among patients ≥65 years old. A robust tool to identify patients who require a CT head will reduce unnecessary testing.

Introduction: Oral sweet solutions have been accepted as effective pain reducing agents for neonates. However studies in the Emergency Department (ED) setting have conflicting results. The objective is to compare the efficacy of an oral sucrose solution versus placebo in reducing pain in children 1 to 3 months of age during nasopharyngeal aspiration (NPA) in the ED. Methods: A randomized, double-blinded, placebo controlled clinical trial was conducted in a pediatric university-affiliated hospital ED. Participants from 1 to 3 months of age requiring NPA were recruited and randomly allocated to receive 2 mls of an 88% sucrose solution (SUC) or 2 mls of a placebo solution (PLA) orally, 2 mins before NPA. The primary outcome was the mean difference in pain scores at 1 min post NPA as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale. Secondary outcomes were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time, heart rate and adverse events. Results: 72 participants were recruited and completed the study, 37 (group SUC) and 35 (group PLA) respectively. Both groups had similar demographic and clinical characteristics and baseline FLACC and NIPS pain scores (all p=value >0.4). The mean difference in FLACC scores compared to baseline was 3.3 (2.5-4.1) (SUC) vs. 3.2 (2.3-4.1) (PLA) (p=.94) at 1 min and -1.2 (-1.7 to 0.7) (SUC) vs. -0.8 (-1.5 to -0.1) (PLA) (p=.66) at 3 mins after NPA. For the NIPS scores, it was 2.3 (1.6-3.0) (SUC) vs. 2.5 (1.8-3.2) (PLA) (p=.86) at 1 min and -1.2 (-1.6 to -0.8) (SUC) vs. -0.8 (-1.3 to 0.2) (PLA) (p=.59) 3 mins after NPA. There was no difference in the mean crying time, 114 (98-130) secs (SUC) vs. 109 (92-126) secs (PLA) (p=.81). No significant difference was found in participants’ heart rate at 1 min 174 (154-194) BPM (SUC) vs. 179 (160-198) BPM (PLA) (p=.32) and at 3 mins 165 (143-187) BPM (SUC) vs. 164 (142-186) BPM (PLA) (p=.86) after NPA. Three patients had vomiting during the procedure (2 PLA and 1 SUC), and one had an episode of chocking (PLA). Conclusion: In infants 1 to 3 months of age undergoing nasopharyngeal aspiration in the ED, administration of an oral sweet solution did not statistically decrease pain scores as measured by the FLACC and NIPS scales. Participants’ heart rate and crying time were not significantly decreased when sucrose was provided.

Introduction: Headache is a common emergency department (ED) presentation. Benign (i.e., non-pathological) headaches are particularly common, including exacerbations of chronic migraine, tension, and cluster headache. Several studies have reported concerns over the frequent use of advanced imaging, specifically computed tomography (CT), in the ED management of benign or primary headache presentations. This systematic review examined the proportion of adult ED benign headache presentations who receive a CT(head). Methods: Eight bibliographic databases and the grey literature were searched. All studies reporting the proportion of benign headache patients receiving a CT(head) in the ED were eligible for inclusion. Studies which included a secondary headache population of 15% of their total study population or less where eligible for inclusion. Two reviewers independently assessed study inclusion and completed quality assessment and data extraction. Weighted medians were calculated for the primary and secondary outcomes, as appropriate. Results: The search returned 2,444 unique citations, of which 20 met the inclusion criteria (21 patient groups were analyzed). The majority of the studies were descriptive in nature and conducted in North America. The reported proportion of benign headache patients receiving a CT(head) varied considerably (range: 2.06-67.21%); with a weighted median of 30.0% (interquartile range: 30.0, 30.0). Studies published in 2000 or later (18/21 groups) were found to have a higher weighted median percentage compared to those published pre-2000 (p=0.016). Neither the country of origin nor the proportion of patients with secondary headache included within the study population had a significant effect on CT utilization. Of the three studies which reported the discharge diagnosis of all patients, sub-arachnoid hemorrhage was discovered in 2/241 (0.83%) of CT scans. Conclusion: Considerable variation in CT utilization for benign headache ED presentations exists and estimates indicate that more than a quarter of patients receive a CT(head). Overall, these CT scans rarely identify significant pathology, suggesting imaging may be safely reduced. Further research is required to identify interventions which can safely and effectively reduce unnecessary imaging among headache presentations.

Introduction: With the increased accessibility of computed tomography (CT), use in the emergency department has increased. Increased use has lead to a reduction in missed diagnoses but also an increase in radiation burden and the increased likelihood of incidental findings. In this study, we sought to characterize the use of abdominal CTs at an academic tertiary center in order to quantify the rate and clinical significance incidental findings. Methods: This was a retrospective chart review of radiological database of all abdominal CT ordered by the emergency department from January 1st to March 21st 2015. Incidental findings requiring follow up were defined by the American college of radiology guidelines. Clinically significant incidental findings were defined as those that resulted in a finding of malignancy or comparably serious disease. Abdominal CTs were excluded if they were ordered together with CT thorax. The data was abstracted by one trained reviewer using a standardized data collection sheet and 10% of the data was verified by a second reviewer. Inter-rater reliability reported by Kappa statistic. Data were reported as mean and standard deviation. 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 1882 imaging studies were included (56.3% female, age 59.4 years (16.3), CTAS 3 (1.3). The most common presenting complaints: abdominal pain (980, 52.1%), flank pain (196, 10.4%) and nausea/vomiting (111, 6%). Indications included rule out (r/o) obstructing renal stones/colic (329; 17.5%), r/o diverticulitis/colitis (307; 16.4%) and abdominal pain not yet differentiated (283; 15.1%). The most common final diagnoses as a result of CT were renal stone/colic (212, 11.3%), colitis/diverticulitis (191, 10.2%), and bowel obstruction (111, 6%).Incidental findings recommending further imaging occurred in 93 (4.9%). Of these, 43 were completed, and 15 resulted in clinically significant findings: cancer of the colon (2), lung (2), bladder (2), metastatic cancer (2), adnexa (4), endometrium (1), lymphoma (1), and venous thrombus (1). Conclusion: Incidental findings are far less common (5%) then previously reported (as high as 30%) and rarely clinically significant.

Introduction: Syncope is a common emergency department (ED) presentation and constitutes 1% of all ED visits, approximately 160,000 visits annually across Canada. Lack of standardized syncope care has economic and cost implications. Currently, emergency medical services (EMS) is over utilized, variations in ED management exist and a substantial proportion (46.5%) are hospitalized for cardiac monitoring. Our previous studies have proposed ways to reduce health care utilization through development of EMS clinical decision tool, ED risk scores and remote cardiac monitoring. We sought to: 1) Estimate costs associated with syncope care in the pre-hospital, ED and inpatient settings; and 2) Determine potential cost savings if the proposed alternate strategies were adopted. Methods: A prospective cohort study was conducted in five Canadian EDs from 2010-2014. We enrolled adult (≥16 years) syncope patients and excluded those with prolonged loss of consciousness, mental status changes, seizure, significant trauma, or alcohol/illicit drug abuse. Demographics, medical history, mode of arrival, EMS time points, reasons for hospitalization, ED and inpatient length of stay, final ED diagnosis and any serious adverse event within 30 days of index visit were collected. Descriptive and inferential statistics were used. Results: Out of 4,064 patients enrolled, 67.3% were transported to the ED by EMS and the average cost per event was $262.78 (range at study sites: $156.43-$553.03). The average cost per ED visit was $267.98 (range: $174.66-$374.95). 12.9% of the patients were admitted and the average of cost per admission was $9,886.15 (range: $9,715.23-$10,277.98). Syncope is associated with an estimated total annual cost of $257 million. In Canada, we estimate that diverting low-risk patients will save $5 million in the pre-hospital setting and $15 million in the ED annually, and implementing a remote cardiac monitoring strategy will save $50 million annually. Conclusion: It is estimated that the proposed strategies will save $70 million annually. This is likely an underestimation as cost savings due to reduction in investigations related to diversion of ED patients, reduction in ED length of stay and hospitalization are unaccounted. Adoption of similar strategies will likely lead to significantly higher cost savings in countries with higher resource utilization for syncope management.

Introduction: Podcasts and blog posts are gaining popularity in Free Open Access Medical education (FOAMed). However, there remains a paucity of research comparing the two media for undergraduate medical education. This study aims to investigate if there are differences in medical students’ usage conditions, knowledge retention and preferences in the two types of media (podcasts, blog posts). Methods: Medical students were block-randomized to either the podcast or blog post group according to their year of schooling. They completed an online assessment of their baseline knowledge on the subject matter and preferences within the various types of media. Participants then received access to learning materials and were given four weeks to complete the follow-up assessment. Simple descriptive statistical data were used to detail student preferences. Paired samples t-tests and a Repeated Measures Analysis of Variance (RM-ANOVA) were conducted to assess knowledge acquisition. A carry forward analysis was used to impute missing data from students lost to follow-up. Results: A total of 65 medical students participated in our study (podcasts n=33, blog posts n=32). The initial survey suggests that students prefer general topic discussion and “approach-to” themes (68% and 84%, respectively). 55% of students in the podcast group preferred podcasts that were less than 30 minutes. None of the blog post group preferred a shorter text, and each blog post required a mean of 25 minutes to read. Completion of at least one follow-up assessment was comparable (68% podcasts, 70% blog posts). The podcast listeners tended to engage in multiple activities while using the learning material (e.g. at least 2-3 of the following: driving, eating, chores, taking notes, exercising), while the blog readers tended to do fewer activities (e.g. only 1 of the following: taking notes, eating, only reading). Both groups showed significant improvements in their test scores (Asthma: 22% improvement, Toxicology: 29%; p<0.01 for both), with blog posts demonstrating a larger but non-significant difference (RM-ANOVA, Topic*Modality F(1,59)=0.001, p=0.973). Conclusion: This study suggests that podcasts and blog posts significantly improve medical student knowledge retention to a similar degree, but differ in usage conditions.

Introduction: The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) found a significant rise in trampoline-related injuries from 1999-2005, many of which required hospitalization. In 2007 and again in 2013, the Canadian Pediatric Society (CPS) recommended against the recreational use of trampolines at home. The purpose of this study was to evaluate the impact of this policy statement on trampoline-related injuries in Halifax, Nova Scotia. Methods: Trampoline injury data was obtained from the CHIRPP database at the IWK Health Centre, the paediatric referral hospital for the Maritimes. The data was stratified according to the timing of the CPS policy statement (before: 2001-2006, after: 2008-2013 and after reaffirmation 2013-2015). Data variables included mechanism, site, nature and context of injury. The data were evaluated using SPSS and chi-squared tests. Results: Since the 2007 CPS policy statement, an average of 162 per 10,000 ED visits at the IWK Health Centre were the result of trampoline-related injuries compared to 95 per 10,000 pre-policy. The majority of injuries (76-80%) occurred in children 5-14 years of age. Recreational use at home in the yard was the most common location of the accident (78-88%), with most injuries occurring on the trampoline mat itself (83-85%) due to incorrect landing (32-35%), falls (21-27%), or being struck by a person or object (24-25%). Soft tissue injuries (15-17%), sprains (19-22%) or fractures (40-46%) to the elbow (11-12%), forearm (5-9%) or ankle (19-21%) continued to be the most common nature and sites of injuries. The injury data before compared to after the CPS policy statement did not differ significantly in gender, the mechanism of injury, the type of injury, or body part involved (p-value >0.05). There was a significant difference in the number of injuries between age groups post-policy, with more occurring in children less than 4 and between the age of 10-14 (p<0.009). Moreover, where the trampoline injury was located was also significantly different post-policy with more injuries occurring in sports/recreational facilities (p<0.001). Conclusion: Trampolining is a high-risk activity with injuries occurring predominantly in children and youth. Despite the recommendations brought forth by the CPS, trampoline-related injuries remain an important source of pediatric injuries at the IWK Health Centre in Halifax, Nova Scotia.

Introduction: Delirium is a very prevalent cognitive impairment in elderly inpatients, but it often goes undetected, especially in the emergency department (ED). The tools currently available to screen or diagnose patients at risk of delirium are very time-consuming and are impossible to systematically perform in the ED environment. For this reason, short tests are necessary to screen for delirium in this fast-paced setting. The objective of this study was to evaluate the performance of the French version of the Rapid Assessment Test for Delirium (4AT) for the detection of delirium and cognitive impairment in older patients. The 4AT takes less than 2 minutes to administer, which is a great advantage on the others tests. Methods: The study was conducted in four emergency departments across the province of Québec. Participants were independent or semi-independent patients aged 65 and older, admitted to hospital and who had an 8-hour exposure to the ED. The Telephone Interview for Cognitive Status (TICS) was administered at the initial interview and the Confusion Assessment Method (CAM) as well as the 4AT were administered to patients twice a day during their ED or hospital stay. The 4AT’s sensitivity and specificity were compared to that of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Results: 324 patients were included in the study, with a mean age of 76 years old. Among the recruited participants, 21 (6.5%) had a prevalent delirium according to the CAM, and 30 (10.2%) had an incident delirium. According to the 4AT, 48 patients (14.9%) had cognitive impairment and 81 (25.2%) had a prevalent delirium. According to the TICS, 87 patients (29.2%) have cognitive impairment. The 4AT has a sensitivity of 68,4% (IC 95% : 47,5-89,3) and a specificity of 73.2% (IC 95% : 67,8-78,7) for delirium, and a sensitivity of 50% (IC 95% : 35,9-64,1) and a specificity of 87,0% (IC 95% : 81,2-92) for cognitive impairment. Conclusion: The French Version of the 4AT could be a fast and reliable screening tool for delirium and cognitive impairment in ED. Further research is necessary for its validation in the ED.

Introduction: We previously reported that a targeted knowledge translation (KT) intervention was associated with a trend towards increased awareness and knowledge of the Choosing Wisely Canada (CWC) emergency medicine (EM) recommendations. We wished to assess if the intervention changed physician practice, specifically looking at the imperative “do not order lumbar XRs for non-traumatic low back pain unless red flags exist”. Methods: A departmental KT initiative was implemented in April 2016 and consisted of a 1-hour seminar reviewing the CWC-EM recommendations, access to a video cast, departmental posters, and a before and after awareness survey. The effectiveness of our intervention was assessed by analyzing the frequency of lumbar XR imaging conducted for low back pain before and after the introduction of our intervention at a tertiary teaching hospital emergency department. All patient visits for the complaint of low back pain were included. The rates of XR imaging from June 2014 to September 2014 for the pre-intervention period and June 2016 to September 2016 for the post-intervention period were collected and analyzed using Fisher exact tests. A sample size of 683 was required to detect a 5% change with an alpha of 0.05 and a power of 80%. Results: Baseline characteristics of patients were similar for the pre- and post-intervention periods. There was a total of 781 patient visits for low back pain in June to September 2014 and 672 in June to September 2016. The XR imaging rate for low back pain increased from 12% (95% CI 9.9-14.5) to 16.2% (95% CI 13.6-19.2) following the intervention (p=0.023). Conclusion: We previously demonstrated a trend towards increased awareness and knowledge of the CWC EM recommendations following a knowledge translation initiative. Baseline XR imaging rates for low back pain were lower than what has been reported. We observed that our intervention was associated with an increased frequency of imaging for low back pain. This may be due to a contrarian effect. We feel this calls into question the role of knowledge translation initiatives where physician practice already closely adheres to pre-established recommendations.

Introduction: The Pulmonary Embolism Severity Index (PESI) score predicts short-term mortality from pulmonary embolism and low-risk patients suitable for home therapy. However, it is unknown if it is a driver for disposition decisions for emergency department (ED) patients. The primary objective of this study was to define the relationship between disposition decisions and the PESI score in Calgary zone hospitals. Methods: The PESI score was calculated retrospectively for 576 patients presenting to one of four Calgary zone hospitals for pulmonary embolism over the last 2 years. The calculated PESI score allowed the mortality risk of each patient to be estimated for very low risk (Class I, 0-1.6% 30-day mortality rate), low risk (Class II, 1.7-3.5% 30-day mortality rate), intermediate risk (Class III, 3.2-7.1% 30-day mortality rate), high risk (Class IV, 4.0-11.4% 30-day mortality rate), and very high risk (Class V, 10.0- 24.5% 30- day mortality rate). The patients were grouped based on being admitted to the hospital for inpatient care, or discharged for outpatient care. Descriptive statistics were used to describe the data. Results: Of the 576 patients, 317 (55%) were discharged and 259 (45%) were admitted to the hospital for inpatient care. Among admitted patients, 20.5% were considered Class I, 29.3% were Class II, 24.3% were Class III, 17.6% were Class IV, and 8.1% were Class V. Among discharged patients, 53.9 % were Class I, 25.6% were Class II, 15.5% were Class III, 4.4% were Class IV, and 0.6% were Class V. Of the 25 very high-risk (Class V) patients, 2 (8.0%) were discharged from the ED and treated as outpatients. Of the 223 very low risk (Class I) patients, 171 (76.7%) were discharged and 52 (23.3%) were admitted to hospital. Conclusion: A significant percentage of pulmonary embolism patients admitted to Calgary Zone hospital wards are PESI low risk (29.3%) or very low risk (20.5%). Implementation of a PESI score-based disposition pathway could improve the safety, cost-effectiveness and quality of ED disposition decisions for PE.

Introduction: The objective of this systematic review was to investigate the psychometric properties and diagnostic performance of instruments used in the emergency department to identify pediatric mental health and substance use problems. Methods: A search of seven electronic databases and the grey literature was conducted. Studies assessing any instrument to identify and or diagnose mental illness, emotional or behavioural problems, or substance use disorders in pediatric patients with presentations for mental health or substance use issues were considered eligible for inclusion. Two independent reviewers judged the relevance and study quality of the studies. A descriptive analysis of the outcomes was reported. Results: From 4832 references, 14 studies were included. Eighteen instruments were evaluated for identifying suicide risk, alcohol use disorders, mood disorders, and ED decision-making. The HEADS-ED has good inter-rater reliability (r=0.785) for identifying general mental health problems and modest evidence for ruling out patients requiring hospital admission (positive likelihood ratio, LR+=6.30). The internal consistency varied for tools to screen for suicide risk (α=0.46-0.97); no tools have both high sensitivity and high specificity. The Ask Suicide-Screening Questionnaire (ASQ) is highly sensitive (98%) and provides strong evidence to rule out risk (negative likelihood ratio, LR−=0.04). Among tools to screen for alcohol use disorders, a two-item tool based on DSM-IV criteria was found to be the most accurate in identifying patients with a disorder (area under the curve: 0.89), and has modest evidence to rule in and rule out risk (LR+=8.80, LR−=0.13). Conclusion: Reliable, valid, and accurate instruments are available for use with pediatric mental health ED visits. Based on available evidence, emergency care clinicians are recommended to use the HEADS-ED to rule in ED admission, ASQ to rule out suicide risk, and DSM-IV two-item tool to rule in/rule out alcohol use disorders.

Introduction: While methods have been developed to assess pain and provide analgesia to hospitalized intubated patients, little is known about current EMS practices in providing similar care during air and land medical transports. Therefore, we sought to determine if opioid analgesia is provided to intubated patients during transportation in out-of-hospital setting. Methods: We conducted a health record review examining electronic records of intubated patients transported by Ornge in 2015. Ornge is the exclusive provider of air and land transport of critically ill patients in Ontario, Canada with over 18,000 transports per year. We identified cases using Ornge’s database and selected intubated patients meeting inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was frequency of administration and dose adequacy of an opioid analgesic. Secondary outcomes included: choice of analgesics used (fentanyl, hydromorphone or morphine), adverse events, and impact of age, sex, or reason for transfer on pain management. We present descriptive statistics. Results: Our strategy identified 500 potential cases, of which 448 met our inclusion criteria. Among those 448 patients, 154 (34.4%) were females, 328 (73.4%) received analgesia and 211 (64.3%) received more than one dose during transport (median frequency of 2 doses, IQR=1 to 3). The average transport time was 148 minutes and repeated dosing (>1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.6%) and most commonly used dose was 50 micrograms (51.8%). Adverse events occurred in 8 (2.5%) patients with 5 patients having new hypotension (MAP <65 mm Hg). There was no significant difference in administration of analgesia based on patient’s age or sex (68.8% of females and 75.3% of male patients received analgesia). Interestingly, 30.8% of patients repatriated to originating-hospital received analgesia compared to 72.3% of patients receiving analgesia for all other reasons for transfers. Conclusion: More than 73% of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex or reason for transfer other than home repatriation.

Introduction/Innovation Concept: Free Open Access Medical education (FOAM) is a rapidly emerging medium for the dissemination of medical knowledge, especially in Emergency Medicine. However, the most contributors to FOAM are EM attendings who write on established platforms which they also maintain. EM learners have difficulty breaking into this quickly evolving field. In an effort to encourage FOAM involvement of trainees early in their careers, CanadiEM recruited 10 junior residents and medical students with the purpose of developing the skills necessary to contribute to FOAM. These Junior Editors actively participate in the blog workflow, developing writing, editorial, and management skills necessary to operate a high-traffic EM website. Methods: Potential candidates were recruited by placing an advertisement and application on the CanadiEM website. 10 medical students or junior residents were invited to online group video interviews and were all accepted as Junior Editors (JE). Senior CanadiEM staff held online training sessions for all new JEs on how to use Wordpress to create, edit and publish posts, as well as basics in Search Engine Optimization. The junior editors collaboratively developed an instructional document containing the information they learned during these sessions. JEs then volunteered for editorial jobs via an online messaging system (Slack) as they became available. After uploading the draft of each post, the final products are reviewed by senior Editor and feedback was given to each JE. Curriculum, Tool, or Material: All JEs have learned to use the Wordpress blogging platform to create, edit, and upload posts; optimize blog posts for search engines. Following their own interests, some JEs have also learned to edit podcasts, promote the blog on social media resources (Twitter and Facebook), create infographics, and copy-edit blog posts. Conclusion: After 8 months, the JE program has yielded 6 very active editors who maintain a strong blog workflow, have well-developed social media skills, and are actively involved in developing their own content for future posts. The JE program is a strong pathway to introduce medical trainees to both the technical and creative aspects of FOAM and serves as a novel approach to transition students from passive utilization of online content to active contributors.

Introduction: In Ottawa, STEMI patients are transported directly to percutaneous coronary intervention (PCI) by advanced care paramedics (ACPs), primary care paramedics (PCPs), or transferred from PCP to ACP crew (ACP-intercept). PCPs have a limited skill set to address complications during transport.The objective of this study was to determine what clinically important events (CIEs) occurred in STEMI patients transported for primary PCI via a PCP crew, and what proportion of such events could only be treated by ACP protocols. Methods: We conducted a health record review of STEMI patients transported for primary PCI from Jan 1, 2011-Dec 21, 2015. Ottawa has a single PCI center and its EMS system employs both PCP and ACP paramedics. We identified consecutive STEMI bypass patients transported by PCP-only and ACP-intercept using the dispatch database. A data extraction form was piloted and used to extract patient demographics, transport times, and primary outcomes: CIEs and interventions performed during transport, and secondary outcomes: hospital diagnosis, and mortality. CIEs were reviewed by two investigators to determine if they would be treated differently by ACP protocols. We present descriptive statistics. Results: We identified 967 STEMI bypass cases among which 214 (118 PCP-only and 96 ACP-intercept) met all inclusion criteria. Characteristics were: mean age 61.4 years, 78% male, 31.8% anterior and 44.4% inferior infarcts, mean response time 6 min, total paramedic contact time 29 min, and in cases of ACP-intercept 7 min of PCP-only contact time.A CIE occurred in 127 (59%) of cases: SBP<90 mmHg 26.2%, HR<60 30.4%, HR>100 20.6%, malignant arrhythmias 7.5%, altered mental status 6.5%, airway intervention 2.3%, 2 patients (0.9%) arrested, both survived. Of the CIE identified, 54 (42.5%) could be addressed differently by ACP vs PCP protocols (25.2% of total cases). The majority related to fluid boluses for hypotension (44 cases; 35% of CIE). ACP intervention for CIEs within the ACP intercept group was 51.6%. There were 6 in-hospital deaths (2.8%) with no difference in transport crew type. Conclusion: CIEs are common in STEMI bypass patients however a smaller proportion of such CIE would be addressed differently by ACP protocols compared to PCP protocols. The vast majority of CIE appeared to be transient and of limited clinical significance.

Introduction: There is increasing evidence that emergency room physicians or primary care physicians can definitively manage many uncomplicated paediatric fractures without orthopaedic follow-up. This strategy leads to a reduction in radiation exposure and decreased costs to patient families and the healthcare system without impacting patient outcomes. The aim of this study was to determine whether patients who sustained a toddler’s fracture of the tibia required orthopaedic surgeon follow-up. Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of toddlers’ fractures between Jan 2009 and Dec 2014 was performed. Results: 186 patients (115 males, 72 females) with an average age of 2.00 (range 0.2-3.9) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.00 (±1.0). The mean number of radiology department appointments was 2.76 (±1.1) where patients received a mean number of 5.86 (±2.6) radiographs. Complications were minimal and no patient developed a non-union nor re-fractured. All patients achieved clinical and radiographic union. To date, no patient has returned to clinic or undergone surgery for concerns regarding leg length inequality or malalignment. Conclusion: Our series supports reduced clinical follow-up of patients with a toddler’s fracture of the tibia. If the diagnosis can be made on the initial radiographs, emergency room physicians or primary care providers can definitively manage these patients with appropriate immobilization that can be removed by the parents between 3-4 weeks after the injury. A fracture clinic follow-up is only necessary if the diagnosis cannot be made on the initial radiographs. Our toddler’s fracture pathway will reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients’ families without jeopardizing patient outcomes.

Introduction: There is increasing evidence that emergency room physicians or primary care physicians can definitively manage many uncomplicated paediatric fractures without orthopaedic follow-up. This strategy leads to a reduction in radiation exposure and decreased costs to patient families and the healthcare system without impacting patient outcomes. The aim of this study was to determine whether patients who sustained an isolated 5th metatarsal fractures require orthopaedic surgeon follow-up. Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of metatarsal fractures from 2009-2014 was performed. Results: 124 patients (66 males, 58 females) with mean age of 11.3 (SD=2.9) years old were included in the study. Complications were minimal with no patients requiring operative management. There were zero non-unions and 3 delayed unions. Despite zero instances of surgical correction and a low complication rate, fracture clinic resource utilization was substantial. Fractures were managed with a mean number of 3.1 (SD=0.98) clinic visits, including initial evaluation in the emergency department. A mean number of 2.8 (SD=1.1) radiology department visits were conducted, with a mean of 8.1 (SD=3.8) x-rays total per patient. Conclusion: Our series supports reduced clinical follow-up of patients with isolated 5th metatarsal fractures. If the diagnosis can be made on the initial radiographs, ER physicians or primary care providers can definitively manage these patients with appropriate immobilization. A fracture clinic follow-up is only necessary if the diagnosis cannot be made on the initial radiographs. Our clinical care pathway will reduce radiation exposure and reduce costs incurred by the healthcare system and patients’ families without jeopardizing patient outcomes.

Introduction: London Health Sciences Centre (LHSC) includes two academic, urban hospitals in London, Canada. The hospital-standardized mortality ratio (HSMR) is consistently higher than provincial and national averages. Unpublished data reveals that sepsis contributes the largest number of statistically unexpected deaths to LHSC’s HSMR calculation. Factors contributing to in-hospital sepsis mortality are hypothesized to include demography, emergency department (ED) flow or sepsis treatment. Methods: Retrospective chart review of patients aged >=18 years, presenting to an LHSC ED between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis (ICD-10 diagnostic codes A4xx and R65). Data were abstracted from electronic health records. Regional, provincial and national data was retrieved from CIHI and Statistics Canada. Results: Median age and sex in London and across Canada are similar (48.2 years vs 48.9 years; 48% male vs 49% male). Baseline prevalences of diabetes, hypertension, COPD and mood disorders were similar in the Local Health Integration Network and Ontario (6% vs 7%, 19% vs 19%, 3% vs 4%, and 10% vs 8%). Median “Physician Initial Assessment,” (PIA) times for sepsis patients at LHSC were faster than median Canadian PIA times for CTAS I and II patients (CTAS I: 7 min vs 11 min, CTAS II: 34 min vs 54 min), and slower for CTAS III-V patients (CTAS III: 98 min vs 79 min, CTAS IV: 99 min vs 66 min, CTAS V: 132 min vs 53 min). Median ED length of stay for admitted, high acuity (CTAS I-III) patients was 6 h at LHSC versus 10 h across Canada.Median [IQR] time to intravenous fluid resuscitation was 60.5 min [29.8-101.2] for septic shock patients and 77.0 min [36.0-127.0] for expired patients. Median [IQR] time to antibiotics was 130 min [73.0-229.0] for sepsis patients, 106 min [60.0-189.0] for severe sepsis patients, and 82 min [42.2-142] for septic shock patients. Conclusion: Excess sepsis-related mortality at LHSC is not convincingly related to patient demographics or ED flow. Gains may be made by improving time to antibiotics and IV fluids.

Introduction: Emergency physicians increasingly encounter young patients with protracted, forceful hyperemesis associated with heavy cannabis use, previously termed “cyclic vomiting.” The national discourse on liberalization of cannabis has largely ignored this poorly understood condition. We wondered to what degree hyperemesis cannabis is an idiosyncratic reaction, like motion sickness or migraine, versus a more predictable dose-response effect of heavy, prolonged use. Methods: As part of a larger case-control study using structured interviews, we measured cannabinoid concentrations in scalp hair of both cases and controls. Cases were required to have an emergency visit for vomiting, 2+ episodes of severe vomiting in the previous year, history of near-daily use of cannabis for 6+ months, positive urine Δ9-tetrahydrocannabinol (THC) and age 16-55 years; exclusion criteria were chronic opioid use, synthetic cannabinoid use, or established alternative diagnosis. Age- and sex-matched chronic cannabis-using controls without vomiting were identified via social referral primarily from the cases themselves. Scalp hair was analyzed for THC, cannabinol (CBN), cannabidiol (CBD) and 11-nor-9-carboxy-THC (THC-COOH) by LC-MS/MS (limit of quantification ~15 pg/mg hair; accuracy <5%) in an independent laboratory blinded to subject classification. Results: We obtained satisfactory hair and urine samples from 18 cases (median [IQR] age 27 [20,31] years; 12 male) and 13 controls. THC and CBN concentrations were higher in cases than controls (THC 240 [120,820] vs 99 [73, 290] pg/mg; CBN 63 [33, 260] vs 15 [negative, 76] pg/mg; each P<0.05). CBD and THC-COOH were often unquantifiable to undetectable in both cases and controls. Conclusion: Hyperemesis cannabis patients have substantially higher hair cannabinoid concentrations than their peers without vomiting, although there is some overlap. The association cannot demonstrate a direct dose-response with THC--confounding (e.g. other cannabinoids, external smoke deposition), altered metabolism and reverse causation (e.g. seeking temporary symptom relief by using more cannabis) could also yield a positive association. Nevertheless, these findings support counselling patients with hyperemesis to reduce or discontinue using cannabis. They also support national regulatory initiatives including education, labelling, and progressive taxation based on potency intended to discourage excessive use.

Introduction: Consultation in the emergency department (ED) is a common component of emergency health care. Consultation is defined as a case in which an ED physician (EP) requests the services of another physician (consultant) for an ED patient to assist, advise, and/or transfer care when the care required is beyond the expertise of the EP’s practice. While consultation is generally considered required and beneficial for patient care, consultation can also have a negative impact by incurring delays in patient flow and disposition. These delays contribute to ED crowding, patient dissatisfaction and, in some cases, worse health outcomes. Using an a priori protocol and accepted methodology, the aim of this systematic review was to update a previous review on the same topic and determine the proportion of 1) ED visits that involve consultation and 2) consultation cases that result in admission. PROPSPERO registration number: CRD42017054054. Methods: Literature search involved multiple electronic databases (e.g., MEDLINE and EMBASE) and grey literature (e.g., Google Scholar and conference abstracts). Study selection was conducted independently by two reviewers and determined by consensus among the two reviewers with disagreements resolved by a third party. Data extraction was conducted independently by two reviewers and determined by consensus among the two reviewers with disagreements resolved by a third party. A descriptive analysis was conducted. Outcome measure data were aggregated and reported with suitable descriptive statistics such as raw or weighted mean, median, or proportion with 95% confidence interval. Results: Literature search yielded 1,584 studies, of which 65 were included. Two-thirds of studies were conducted in USA or Canada. Of the 65, 54 were focused on a particular patient group or consulting specialty (e.g., psychiatry) while 11 considered the general ED population. Of these 11, the median proportion of ED visits involving consultation was 26%. The median proportion of cases with consultation that resulted in admission was 60%. Conclusion: Consultations in the ED are quite common and many of these cases result in admission. Given their frequency of occurrence and increasing ED crowding, efforts to reduce consult delays and expedite disposition appear warranted.