Introduction: Hypotension is known to be associated with increased mortality in severe traumatic brain injury (TBI) patients. Systolic blood pressure (SBP) of <90 mmHg is the threshold for hypotension in consensus TBI treatment guidelines; however, evidence suggests hypotension should be defined at higher levels for these patients. Our objective was to determine the influence of hypotension on mortality in TBI patients requiring ICU admission using different thresholds of SBP on arrival at the emergency department (ED). Methods: Retrospective cohort study of patients with severe TBI (Abbreviated Injury Scale Head score ≥3) admitted to ICU at the QEII Health Sciences Centre (Halifax, Canada) between 2002 and 2013. Patients were grouped by SBP on ED arrival ( <90 mmHg, <100 mmHg, <110 mmHg). We performed multiple logistic regression analysis with mortality as the dependent variable. Models were adjusted for confounders including age, gender, Injury Severity Score (ISS), injury mechanism, and trauma team activation (TTA). Results: A total of 1233 patients sustained a severe TBI and were admitted to the ICU during the study period. The mean age was 43.4 ± 23.9 years and most patients were male (919/1233; 74.5%). The most common mechanism of injury was motor vehicle collision (491/1233; 41.2%) followed by falls (427/1233; 35.8%). Mean length of stay in the ICU was 6.1 ± 6.4 days, and the overall mortality rate was 22.7%. SBP on arrival was available for 1182 patients. The <90 mmHg group had 4.6% (54/1182) of these patients; mean ISS was 20.6 ± 7.8 and mortality was 40.7% (22/54). The <100 mmHg had 9.3% (110/1182) of patients; mean ISS was 19.3 ± 7.9 and mortality was 34.5% (38/110). The <110 mmHg group had 16.8% (198/1182) of patients; mean ISS was 17.9 ± 8.0 and mortality was 28.8% (57/198). After adjusting for confounders, the association between hypotension and mortality was 2.22 (95% CI 1.19-4.16) using a <90 mmHg cutoff, 1.79 (95% CI 1.12-2.86) using a <100 mmHg cutoff, and 1.50 (95% CI 1.02-2.21) using a <110 mmHg cutoff. Conclusion: While we found that TBI patients with a SBP <90 mmHg were over 2 times more likely to die, patients with an SBP <110 mmHg on ED arrival were still 1.5 times more likely to die from their injuries compared to patients without hypotension. These results suggest that establishing a higher threshold for clinically meaningful hypotension in TBI patients is warranted.

Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.

Introduction: The number of CT scans prescribed in the Emergency department (ED) for suspected renal colic has increased over recent years without an associated improvement in patient-centred outcomes. We assessed whether Point-of-Care Ultrasound (PoCUS) decreases the use of formal radiologic imaging. Methods: We completed a retrospective cohort study on consecutive patients 18 years of age and older presenting to the ED with suspected uncomplicated renal colic in a tertiary care centre in Québec in 2016. Exclusion criteria included: previous urologic intervention, solitary kidney, dialysis, fever, pyuria, acute kidney injury, pregnancy, suspicion of a serious alternative diagnosis or persistent symptoms despite analgesia. We compared the proportion (95%CI) of formal radiologic imaging performed (Ultrasound or CT) in patients who had PoCUS in the ED vs. those who did not. Two-tailed Fisher exact test (α = 0.05) and odds ratios (95%CI) calculated from multivariate logistic regression models adjusted for age, gender, Charlson Index and previous renal colic were used to compare the two groups. The reliability of data collection was evaluated with a kappa score (95%CI). Results: 169 patients with uncomplicated renal colic were included. There was no difference between the groups in terms of age, gender, Charlson Index, or previous renal colic. The PoCUS level of training and the doctor's education level was significantly higher in the PoCUS group. There was a non-significant trend towards less formal imaging in patients of the PoCUS group 65/88 (73.9% [63.4-82.7%]) vs. the non-PoCUS group 69/81 (85.2% [75.6-92.1%]), p = 0.087. After adjustment for confounders, the patients not evaluated with PoCUS were more likely to have formal imaging with a significant odds ratio of 2.41 [1.05-5.56]). Among patients who underwent a CT, incidentalomas were found in 16.5% and only 2.0% demonstrated significant findings leading to changes in ED management, such as an alternative diagnosis, need for admission, or an urgent urological intervention. Inter-observer agreement was excellent between assessers with a kappa score of 0.88 [0.66-1.00]. Conclusion: ED patients with uncomplicated renal colic who are investigated with PoCUS tend to have fewer formal imaging test. When CT scans were performed, incidentalomas were found in 16.5% and ED management changed only 2.0% of the time. PoCUS appears to be a useful tool for decreasing CT utilisation in this low-risk ED population.

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Introduction: The Canadian C-Spine rule (CCR) was validated for use by paramedics to selectively immobilize stable trauma patients. However, the CCR “Dangerous Mechanism” is highly prevalent in sports. Our objective was to compare the CCR performance in sport-related vs. non-sport-related injuries and describe sport-related mechanisms of injury. Methods: We reviewed data from the prospective paramedic CCR validation and implementation studies in 7 Canadian cities, which already included identification of sport-related injuries. A single trained reviewer further categorized mechanisms of injury using a pilot-tested standardized form, with the aid of a sport medicine physician in 15 ambiguous cases. We compared the CCR's recommendation to immobilize sport-injured versus non-sport-injured patients using chi-square and relative risk statistics with 95% confidence intervals. Results: There were 201 amateur sport-injuries among the 5,978 patients. Sport-injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs 46.8%) than non-sport-injured patients. Paramedics did not miss any c-spine injuries when using the CCR. Although cervical spine injury rates were similar between sport (2/201; 1.0%) and non-sport injured patients (47/5,777; 0.8%), the absolute number of sport-related injuries was very small. Although CCR recommended immobilization equally between the two groups (46.4% vs 42.5% p = 0.29; RR 1.17 95%CI 0.87-1.57), the reason for immobilization was more likely to be a dangerous mechanism in sport injuries (68.6% vs 54.5%, p = 0.012). Although we observed a wide range of mechanisms, the most common dangerous mechanism responsible for immobilization in sport was axial load. Conclusion: The CCR identified all significant c-spine injuries in a cohort of patients assessed and transported by paramedics. Although an equal proportion of sport and non-sports related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the CCR to evaluate all sport-related injuries in collegiate or pro athletes evaluated by sport medicine therapists and physicians, as these patients are rarely assessed by paramedics or transported to a hospital. It does support the safety and benefit of using the CCR in sport-injured patients for which paramedics are called.

Introduction: Successful resuscitation in the ED cannot occur without a viable patient, and in many cases patient viability is dependent upon optimal prehospital resuscitation performed by ad hoc teams formed in real time. Currently, little is known about the cognitive and interpersonal skills, or non-technical skills, that are essential for effective team collaboration under these conditions. We have completed a scoping review to provide a state of the literature and develop a taxonomy of the non-technical skills pertinent to ad hoc teams in prehospital settings. Methods: Our scoping review searched four databases (EMBASE, Medline, Cinahl, and Psychinfo) for articles related to resuscitation in acute care settings. No date criteria were applied, but only full text articles written in English were included. Articles underwent two-reviewer title & abstract screening, full text screening, and analysis. A quality review asked three questions: Are keywords defined? Is the article well-situated within the existing literature? Does the article contribute back to the existing body of knowledge? Although statistical analyses are not appropriate for this scoping review, analysis included a descriptive-analytical framework for organizing data. Results: Of 6932 screened articles, 38 were included in analysis, five articles examined prehospital teams, and one addressed the ad hoc nature of these teams. Only one of these articles met our three quality criteria. Nevertheless, our analysis suggests a rudimentary taxonomy whereby the primary objective of a team leader is to overcome this barrier by facilitating the development of optimal team situational awareness, fostered through timely and accurate briefings with closed-loop communication. Conclusion: This scoping review has identified that non-technical skills pertaining to resuscitation in acute care settings are becoming a widely examined phenomenon; however, few studies contribute in any meaningful way to our understanding of how non-technical skills training can be tailored to those performing as members of ad hoc prehospital resuscitation teams. As the need for interprofessional training is becoming more pressing, we anticipate this review will provide essential guidance for future inquiry as well as design for both educational models and organizational systems-based interventions.

Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.

Introduction: Delay of hospital admission until completion of assessment by consultants is a major contributor to emergency department (ED) crowding. We measured emergency physicians’ (EP) ability to predict patient admission, and estimated potential time saved if EPs could request a bed at the time of consultation. Methods: This is a prospective cohort study in a tertiary care center over 4 months using a convenience sample of ED patients requiring consultation. We consecutively recruited patients from purposefully selected shifts to balance day of the week and time of day. We excluded patients younger than 18 years or those likely to be admitted (traumas, strokes, STEMI codes, and CTAS1). We asked EPs to predict patient disposition (admission or alternate disposition) just before consultation. We defined admission as: admission to any service, admission within 48 hours of ED discharge, patients held overnight without bed request, or if bed request was delayed by 12 or more hours, and alternate disposition as any other disposition. We present EP prediction test characteristics using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI). The potential time saved was calculated from consultation to bed request for admitted patients. Results: Characteristics for the 454 included patients were: mean age 60.1 years, 48.4% male, 46.9% evening presentation, 69.4% were admitted (most commonly by Internal Medicine 26.9%), and median consult to bed request time was 3.5 hours (interquartile range 2.0 – 5.3 hours). Overall EP prediction sensitivity, specificity, PPV and NPV were 90.5% (95%CI 86.7-93.5), 84.2% (95%CI 77.0-89.8), 92.8% (95%CI 89.8-95.0) and 79.6% (95%CI 73.4-84.7) respectively. In other words, EPs correctly predicted 92.8% of patient admissions. The PPV for Internal Medicine was 95.7% (95%CI 89.7-98.4) and ranged from 78.9% (95%CI 53.9-93.0) for Psychiatry to 100% (95%CI 78.1-100) for Family Medicine. A total of 1113.5 hours of ED stretcher time (37.1 hours per shift) could have been saved if EPs initiated a concurrent bed request at time of consultation. Conclusion: EPs correctly predicted 92.8% of patient admissions across a broad field of disciplines. We estimate 1113.5 hours of ED stretcher time could have been saved over the study period if EPs triggered an inpatient bed request at the time of consultation, rather than waiting for the consultants’ disposition decision.

Introduction: Accurate forecasting of emergency department (ED) patient visits can inform better resource matching. Calendar variables such as day of week and time of day are routinely used as predictors of ED volume. Further improvement in forecasting will likely come from dynamic variables. The effect of snowfall on ED volumes in colder climates remains poorly understood. We sought to determine whether accounting for snowfall improves ED patient volume forecasting. Our secondary objective was to characterize the magnitude of effect of snowfall on ED volume. Methods: This was a retrospective observational study using historical patient volume data and local snowfall records from April 1st, 2011 to March 31st, 2018 (2,542 days) at a single urban ED. We fit a series of four generalized linear models: a baseline model which included calendar variables and three different snowfall models which contained the variables in the baseline model plus an indicator variable for modelling snowfall. Each snowfall model had a different daily threshold for its indicator variable: any snowfall ( >0cm), moderate snowfall ( > = 1 cm), or high snowfall ( > = 5 cm). We modeled daily ED volume as the dependent variable using a Poisson distribution. To evaluate model fit, we examined the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) in each of the four models. In both cases, a lower number indicates better model fit. Incident rate ratios were calculated to determine the effect of snowfall. We used the delta method to calculate confidence intervals. Results: A total of 2542 days were used to develop the model. All three snowfall models demonstrated improved model fit compared to the baseline model with lower AIC and BIC values. The best fitting model included a binary variable for moderate snowfall ( > = 1cm/day). This model showed a statistically significant decrease in ED volume of 2.65% (95% CI: 1.23% -4.00%) on snowfall days, representing 5.4 (95% CI: 2.5 -8.2) patients per day at our hospital with an average daily volume of 205 patients. Conclusion: The addition of a snowfall variable results in improved forecasting model performance in ED volume forecasting with optimal threshold set at 1 cm of snow in our setting. Snowfall is associated with a modest, but statistically significant reduction in ED volume.

Introduction: Emergency department (ED) congestion is an ongoing threat to quality care. Traditional measures of ED efficiency use census and wait times over extended time intervals (e.g. per year, per day), failing to capture the hourly variations in ED flow. Borrowing from the traffic theory framework used to describe cars on a freeway, ED flow can instead be characterized by three fundamental parameters: flux (patients traversing a care segment per unit time), density (patients in a care segment per unit time), and duration (length of stay in a care segment). This method allows for the calculation of near-instantaneous ED flux and density. To illustrate, we examined the association between stretcher occupancy and time to physician initial assessment (PIA), seeking to identify thresholds where flux and PIA deteriorate. Methods: We used administrative data as reported to government agencies for 115,559 ED visits from April 1, 2014 to March 31, 2016 at a tertiary academic hospital. Time stamps collected at triage, PIA, and departure were verified by nosologists and used to define two care segments: awaiting assessment or receiving care. Using open-source software developed in-house, we calculated flow measures for each segment at 90-minute intervals. Graphical analysis was supplemented by regression analysis, examining PIA times of high (CTAS 1-3) or low (CTAS 4-5) acuity patients against ED occupancy (=density/staffed stretchers) adjusting for the day of the week, season and fiscal year. Results: At occupancy levels below 50%, PIA times remain stable and flux increases with density, reflecting free flow. Beyond 50% occupancy, PIA times increase linearly and flux plateaus, indicating congestion. While PIA times further deteriorate above 100% occupancy, flow is maintained, reflecting care delivery in non-traditional spaces (e.g. hallways). An inflection point where flux decreased with increased crowding was not identified, despite lengthening queues. Conclusion: The operational performance of a modern ED can be captured and visualized using techniques borrowed from the analysis of vehicular traffic. Unlike cars on a jammed roadway, patients behave more like a compressible fluid and ED care continues despite high degrees of crowding. Nevertheless, congestion begins well below 100% occupancy, presumably reflecting the need for stretcher turnover and saturation in subsegmental work processes. This methodology shows promise to analyze and mitigate the many factors contributing to ED crowding.

Introduction: Planning for the future emergency physician (EP) workforce will be a significant challenge for decision makers given the rise in emergency department (ED) visits and no concurrent increase in resident positions. EP workforce planning must incorporate physician supply, as well as current and forecasted patient demand. Nova Scotia has undertaken the process of developing a planning model to support policy decision making. We hypothesize that Nova Scotia will require increased resident positions and recruitment from other provinces to meet future patient demand. Methods: We have developed an age structured population model that tracks the number of clinical full-time equivalent (FTE) EPs by their age and shows the “variance” (i.e., supply – demand = variance) over a 30 year planning horizon. This model represents all Level 1, 2, 3, and 4 EDs in Nova Scotia. Current physician supply was calculated based on FTE staffing levels. The current patient demand was based on historical volume and acuity of patients and converted to an FTE demand estimate. Forecasted demand was predicted to increase at an average rate of 0.5% per year. We varied the number of residents trained and the number of EPs recruited from outside the province to examine the effect on the EP workforce. Our initial model will reflect the current training environment and will be referred to as the “current state”. In our 3 scenarios, we increased the number of residents and recruited physicians by 50%, individually and then together. Our outcome measure will be the variance in FTE. Results: The current state showed that the province will have a deficit of 51 FTE EPs over the next 30 years. In scenario 1, a 50% increase in both resident training streams eliminated all variance, while in scenario 2, the increase in recruitment reduced the FTE variance to 34 FTE positions unfilled. In scenario 3, the variance was 0. Conclusion: We feel that this CTAS weighted volumes perspective is important for clinical services planning but the siting, sizing, and synergizing of EDs in a region will involve other inputs. Its important to recognize that we have made the assumption that all physicians starting to work in Nova Scotia will be a 1 FTE. Future iterations will examine the effect of more realistic FTE definitions that account for administrative, teaching and research activities.

Introduction: The Ontario emergency department (ED) Return Visit Quality Program (RVQP) launched in 2016 and aims to promote continuous quality improvement (QI) in the province's largest EDs. The program mandates routine audits of cases involving patients who had ED return visits within 72hrs that led to admission to hospital, in order to identify quality issues that can be tackled through QI initiatives. Our objective was to formally evaluate how well the RVQP achieved its aim of promoting continuous QI at participating sites using the constructivist grounded theory. Methods: Using a semi-structured interview guide, we employed a maximum variation sampling approach to ensure diverse representation across several geographical and institutional experiences (e.g., urban vs. rural, academic vs. community). Selected RVQP program leads were invited to participate in a phone interview to yield maximal insight, additionally using a snowball sampling approach to reach non-lead physicians to capture the penetration of the program. Interviews were conducted until thematic saturation was reached and no new insights were gleaned. Interviews were initially cross-performed by two members of the research team, recorded, transcribed, and de-identified. Data analysis was conducted using a constant comparative approach through the development of a coding framework and triangulation with the respondents’ ED setting. We then grouped, compared and refined our analytic categories through an inductive, iterative approach. Results: Between June and August 2018, we interviewed 32 participants, including 21 RVQP program leads and 11 non-lead physicians, from a total of 23 diverse sites (out of 84). Our analysis suggests that the RVQP provides a structured method for EDs to frame the continuous collection of data in order to channel activities towards quality improvement projects based on identified needs. Success factors included: greater involvement with QI processes prior to the RVQP leading to more openness to improvement, a more collaborative approach to RVQP implementation which led to greater front-line workers’ understanding and engagement, and more resources dedicated to implementing the RVQP as well as tackling the quality issues it identified. Conclusion: This study evaluated the impact of an innovative and large-scale program aimed at improving the culture of quality in Ontario EDs. While the program is still relatively new, early results show that there are key elements of EDs that support building a culture of QI.

Introduction: Access block (AB) is the most important indicator of Emergency Department (ED) crowding, but the impact of AB on consultation time has not been described. Our objectives were to determine if ED AB affects inpatient service consultation time, and operational and patient outcomes. Methods: We conducted a health records review of all ED patients referred and admitted at a university-affiliated tertiary care hospital over 60-days. A computational algorithm determined hourly ED AB at the time of consultation request, and observational cohorts were determined based on ED AB high (>35% ED bed capacity occupied by admitted patients) or low (<35%). The outcomes included total consultation time (TCT), ED physician initial assessment (PIA) time, ED length of stay (LOS), transfer time to inpatient bed (TTB), hospital LOS, return to ED (RTED) within 30 days, and 30-day mortality. Results: We included 2,871 patients (48% male; M = 63 years, IQR 45–78), and the low AB cohort were higher acuity (N = 1,692; 50.4% CTAS 1–2) than the high AB cohort (N = 1,179; 47.1% CTAS 1–2). Median TCT was not significantly different (low = 209min, high = 212min; p = 0.09), and there was no difference in consults completed within the 3-hour institutional time target (low = 41.1%, high = 40.9%; p = 0.89). Median ED PIA time was not significantly different (low = 66min, high = 68min; p = 0.08), however, patients seen within the funding-associated provincial ED PIA time target was significantly less during high AB (high = 82.2%, low = 89.2%; p < 0.001). Median ED LOS was significantly longer during high AB (high = 12.1hr, low = 11.1hr; p = 0.009), but median hospital LOS was not different (high = 109.5hr, low = 112.4hr; p = 0.44). Median TTB was significantly longer during high AB (high = 8.0hr, low = 5.9hr; p = 0.0004). There was no difference in RTED visits (high = 12.4%, low = 10.6%; p = 0.15) or 30-day mortality (high = 8.4%, low = 9.2%; p = 0.51). Conclusion: In conclusion, consultation time is not affected by AB. However, boarding admitted patients in the ED impairs our ability to meet funding-associated performance metrics. Reducing boarding time should be an ED and hospital-wide priority, as it negatively impacts funding and delays patient care.

Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.

Introduction: CTAS triage acuity and CEDIS complaint categories are used to prioritize patients for rapid treatment and ED resource allocation. Our objective was to evaluate CTAS and CEDIS validity for risk stratification of ED patients with chest pain using data from two Canadian cities. Methods: This administrative database study included patients seen over a five-year period with a triage complaint of chest pain. Our composite primary outcome included 7-day mortality, cardiac arrest, acute coronary syndrome (ACS) diagnosis (STEMI, NSTEMI, unstable angina{UA}), admission to a critical care unit, or hospitalization with CHF, pulmonary embolism, dysrhythmia, aortic pathology, neurologic or respiratory diagnosis. We dichotomized triage assignments to cardiac vs. noncardiac chest pain and high (CTAS 1,2) vs. low (3,4,5) triage acuity. For our secondary outcome we reported the components of the primary composite outcome. Results: We studied 111,824 patients. The most common overall diagnoses were chest pain NYD (53.8%), ACS (8.9%), musculoskeletal (7.4%), and acute respiratory (5.5%) or GI (5.1%) conditions. Of all patients studied, 85,888 (76.8%) were placed in the “cardiac features” group, and 93,257 (83.4%) fell into high acuity CTAS 1-2. Patients triaged into the “cardiac features” group were more likely to have a composite outcome event (16.6% v. 6.7%; p < 0.001), to be admitted (21.8% v. 9.0%), to require critical care (6.0% v. 0.7%), to receive an ACS diagnosis (11.3% v. 0.9%), and to die within 7 days (0.5% v. 0.2%). Patients in high acuity triage levels were also more likely to have a composite outcome event (15.8% v. 3.3%; p < 0.001), to be admitted (25.4% v. 14.3%), to require critical care (8.2% v. 1.2%), to receive an ACS diagnosis (10.5% v. 0.9%), and to die within 7 days (0.5% v. 0.2%). Conclusion: This study shows that triage assignment is strongly correlated with important patient outcomes and that both the chief complaint and acuity level are powerful risk predictors. These findings may differ at other sites and hospitals should assess and evaluate their data.

Innovation Concept: High-quality cardiopulmonary resuscitation saves lives; however, current certification standards can leave providers poorly prepared to perform effective chest compressions (CCs). We designed a training program based on the emerging model of skill maintenance through frequent short practice sessions. The ideal frequency of training is currently unknown. Our goal was to provide medical students with access to efficient and effective CC training and to determine an optimal training interval. Methods: Thirty-six second-year medical students were randomized to three groups that trained at different frequencies: once every two months (q2m) (n = 12), once every four months (q4m) (n = 13), and control (n = 11). Study duration was eight months with the intervention groups, q2m and q4m, participating in five and three sessions respectively. The control group was assessed at study start and end, receiving no training in between. At each session, participants completed a one-minute pre-test of CC performance, viewed a one-minute training video, practiced CCs for two minutes with real-time feedback, and completed a one-minute post-test. Performance parameters measured were CC depth, rate, release, and hand positioning. A final “compression score” assessed integrated performance across these parameters and served as our primary outcome. Participants also reported pre- and post-training comfort with performing CCs which served as our secondary outcome. Curriculum, Tool or Material: Our “Quick Refresher Sessions” (QRS) were completed by participants independently without requiring an assessor or facilitator. A manikin with the ability to record and provide real-time quantitative feedback on CC quality was connected to a laptop running a customized interface. Participants typed in an individualized code and were guided through their six-minute sessions automatically. Conclusion: Immediately following the first training session, subjects had significant improvement in compression score (p < 0.001) and skill comfort (p < 0.001). At eight months, both intervention groups, q2m and q4m, achieved higher compression scores than control (p = 0.001 and p = 0.011) and showed greater increase in comfort level (p = 0.002 and p = 0.010). Performance between intervention groups at eight months was not statistically different. Overall, we conclude that independent QRS training every two or four months led to improved CC quality and provider comfort. Future directions include increasing sample size and tailoring training intervals to individual performance.

Innovation Concept: The outcome of emergency medicine training is to produce physicians who can competently run an emergency department (ED) shift. While many workplace-based ED assessments focus on discrete tasks of the discipline, others emphasize assessment of performance across the entire shift. However, the quality of assessments is generally poor and these tools often lack validity evidence. The use of entrustment scale anchors may help to address these psychometric issues. The aim of this study was to develop and gather validity evidence for a novel tool to assess a resident's ability to independently run an ED shift. Methods: Through a nominal group technique, local and national stakeholders identified dimensions of performance reflective of a competent ED physician. These dimensions were included in a new tool that was piloted in the Department of Emergency Medicine at the University of Ottawa during a 4-month period. Psychometric characteristics of the items were calculated, and a generalizability analysis used to determine the reliability of scores. An ANOVA was conducted to determine whether scores increased as a function of training level (junior = PGY1-2, intermediate = PGY3, senior = PGY4-5), and varied by ED treatment area. Safety for independent practice was analyzed with a dichotomous score. Curriculum, Tool or Material: The developed Ottawa Emergency Department Shift Observation Tool (O-EDShOT) includes 12-items rated on a 5-point entrustment scale with a global assessment item and 2 short-answer questions. Eight hundred and thirty-three assessment were completed by 78 physicians for 45 residents. Mean scores differed significantly by training level (p < .001) with junior residents receiving lower ratings (3.48 ± 0.69) than intermediate residents who received lower ratings (3.98 ± 0.48) than senior residents (4.54 ± 0.42). Scores did not vary by ED treatment area (p > .05). Residents judged to be safe to independently run the shift had significantly higher mean scores than those judged not to be safe (4.74 ± 0.31 vs 3.75 ± 0.66; p < .001). Fourteen observations per resident, the typical number recorded during a 1-month rotation, were required to achieve a reliability of 0.80. Conclusion: The O-EDShOT successfully discriminated between junior, intermediate and senior-level residents regardless of ED treatment area. Multiple sources of evidence support the O-EDShOT producing valid scores for assessing a resident's ability to independently run an ED shift.

Innovation Concept: Assessment of residents' Point of Care Ultrasound (PoCUS) competency currently relies on heterogenous and unvalidated methods, such as the completion of a number of proctored studies. Although number of performed studies may be associated with ability, it is not necessarily a surrogate for competence. Our goal was to create a single Ultrasound Competency Assessment Tool (UCAT) using domain-anchored entrustment scoring. Methods: The UCAT was developed as an anchored global assessment score, building on a previously validated simulation-based assessment tool. It was designed to measure performance across the domains of Preparation, Image Acquisition, Image Optimization, and Clinical Integration, in addition to providing a final entrustment score (i.e., OSCORE). A modified Delphi method was used to establish national expert consensus on anchors for each domain. Three surveys were distributed to the CAEP Ultrasound Committee between July-November 2018. The first survey asked members to appraise and modify a list of anchor options created by the authors. Next, collated responses from the first survey were redistributed for a re-appraisal. Finally, anchors obtaining >65% approval from the second survey were condensed and redistributed for final consensus. Curriculum, Tool or Material: Twenty-two, 26, and 22 members responded to the surveys, respectively. Each anchor achieved >90% final agreement. The final anchors for the domains were: Preparation – positioning, initial settings, ensures clean transducer, probe selection, appropriate clinical indication; Image Acquisition – appropriate measurements, hand position, identifies landmarks, visualization of target, efficiency of probe motion, troubleshoots technical limitations; Image Optimization – centers area of interest, overall image quality, troubleshoots patient obstacles, optimizes settings; Clinical Integration – appropriate interpretation, understands limitations, utilizes information appropriately, performs multiple scans if needed, communicates findings, considers false positive and negative causes of findings. Conclusion: The UCAT is a novel assessment tool that has the potential to play a central role in the training and evaluation of residents. Our use of a modified Delphi method, involving key stakeholders in PoCUS education, ensures that the UCAT has a high degree of process and content validity. An important next step in determining its construct validity is to evaluate the use of the UCAT in a multi-centered examination setting.

Background: Greater than 80% of patient visits to emergency departments (EDs) are for a pain-related concerns. Approximately 38,000 patients per year have such complaints in our academic hospital ED. 3,300 (8.6%) of those visits are for musculoskeletal (MSK) pain (i.e. back or extremity injury/pain), which are typically triaged as low-acuity presentations, leading to longer times to clinician assessment. Delays to adequate analgesia result in unnecessary suffering, worse patient care and satisfaction, and increased patient complaints. Aim Statement: We aimed to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 minutes) in 9 months’ time (May 2018). Measures & Design: Our outcome measures were TTA (in minutes) and ED length of stay (LOS; in minutes). Process measures included nurses’ use of medical directive and rate of analgesia administration. Balancing measures included patient adverse events and time spent triaging for nurses. We utilized weekly data capture for the Statistical Process Control (SPC) chart, and we used Mann-Whitney U test for our before-and-after evaluation. Utilizing the Model for Improvement, we performed wide stakeholder engagement and root cause analyses, and we created a Pareto chart. This led to our Plan-Do-Study-Act (PDSA) cycles: 1) nurse-initiated analgesia (NIA) at triage; 2) new triage documentation aid for medication administration; 3) quick reference medical directive badge tag for nurses; 4) weekly targeted feedback of the project's progress at clinical team huddle. Evaluation/Results: TTA decrease from 129 minutes (n = 153) to 100 minutes (22.5%; n = 87, p < 0.05). ED LOS decreased from 580 minutes (n = 361) to 519 minutes (10.5%; n = 187; p = 0.77). Special cause variation was identified on the ED LOS SPC chart with eight consecutive points below the midline, after PDSA 1. The number of patients who received any analgesia increased from 42% (n = 361) to 47% (n = 187; p = 0.13). The number of patients who received medications via medical directives increased from 22% (n = 150) to 44% (n = 87; p < 0.001). Balancing measures were unchanged. Discussion/Impact: The significant reduction in the TTA and increase in the use of medical directives in the before-and-after analyses were likely due to our front-line focused improvements and deliberate nursing engagement. With continued success and sustainable processes, we are planning to spread our project to other EDs and broaden our initiative to all pain-related concerns.

Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures & Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.