Introduction: Endotracheal intubation (EI) is frequently performed in the emergency department (ED). Although this procedure is generally life-saving, EI is also known to cause adverse effects, such as hemodynamic alterations. A systolic blood pressure <90 mmHg is the most commonly accepted definition of hypotension; however systolic blood pressure naturally increases with age. The National Trauma Triage Protocol now states that this threshold could be raised to 110 mmHg in older patients. Objective: to determine the impact of increasing the post-intubation hypotension (PIH) threshold to 110 mmHg on hospital length of stay and mortality in older patients. Methods: Design: A historical cohort of patients admitted in a level-1 trauma center ED between 06/2011 and 05/2016 was constituted. Population: Patients were included if pre-EI vital signs were available, their intubation was performed in the resuscitation room, were aged ≥65, if no surgical access was needed and if EI was performed in ≤3 attempts. Measures: All clinical data including vitals were prospectively recorded using the software ReaScribe. Main outcome was in-hospital mortality. Analyses: Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: A total of 181 patients were included. When using the 90-mmHg threshold, 92 patients suffered from PIH. Mean length of stay for these PIH patients was 18.9 days, compared to 12.0 days for non-hypotensive patients (P = 0.06). Mortality rate at 24 hours was 9.78% and 15.83% for PIH and non PIH patients, respectively (p = 0.2). The 110-mmHg threshold identified 33 additional PIH patients (n = 125) and their mean length of stay was 17.8 compared to 10.2 days for non PIH patients (P = 0.02). Mortality rate at 24 hours was 9.90% for PIH patients and 21.43% for non PIH patients (p = 0.02). Conclusion: PIH was associated with a significant increase in LOS when the PIH threshold is set at 110. Mortality rate is high in the intubated ED older patient and that increasing hypotension threshold for older patient seem to have no impact on patient mortality at 24 hours. Since our sample is limited, more research is needed to confirm these results.

Introduction: Hypotension is known to severely impact the prognosis of patients in need of acute care. Endotracheal intubation (EI) is a procedure that is often used in the emergency room for patients with severe conditions. Post-intubation hypotension (PHI) is a well-known adverse effect of EI, although the impact of PHI on mortality is still unclear. The objective of this study was therefore to evaluate the association between post-intubation hypotension (PIH) and in-hospital mortality rates and length of stay (LOS). Methods: Design: A historical cohort of patients admitted in a university-affiliated emergency department (ED) between 06/2011 and 05/2016 was constituted. Population: Patients aged ≥16 were included if pre-EI vital signs were available, if their intubation was performed in the resuscitation room, if no surgical access was needed and if EI was performed in ≤3 attempts. Measures: All clinical data including vitals were prospectively recorded using the software ReaScribe. Hypotension was defined as a systolic blood pressure ≤90 mmHg. The occurrence of PIH was assessed at 5, 15, 30 minutes and any time after intubation. Main outcomes were in-hospital mortality and hospital length of stay. Analyses: Univariate and multivariate analyses assessed the relation between PHI and outcomes. Results: A total of 497 patients were included in our analyses. Of these patients, 63 (12.7%) suffered from PIH at 5 minutes, 120 (24,1%) at 15 minutes, 168 (33,8%) at 30 minutes and 209 (42%) at any moment after intubation. Mortality rates were 42.9% (n = 27), 35.8% (n = 43), 33.9% (n = 57) and 30.6%(n = 64) for patients who presented PIH at the 4 time periods, respectively, while 26.74% patients died in the normotensive group. PIH at 5 (p = 0.006), 15 (p = 0.04) and 30 minutes (p = 0.05) was associated with a significant increase in overall post-intubation mortality. Mean LOS for patients who suffered from PIH was 16.7, 18.9, 17.3, 17.4 days compared to 19.5 (p = 0.22) days for the normotensive group. Conclusion: Early post-intubation hypotension at 5 minutes was strongly associated with an increased mortality. As for the in-hospital length of stay, PIH was not associated with an increased LOS. Our results show that PIH within 30 minutes of intubation is associated with an increased mortality rate and should therefore be aggressively treated or prevented.

Introduction: Morbidity and mortality from opioid overdoses continue to be a significant issue worldwide. In Alberta, there was a 40% increase in accidental opioid-related deaths from 2016 to 2017. In response to this crisis, Alberta Health Services has dramatically expanded access to Naloxone with a province-wide program for the distribution of take-home naloxone (THN) kits. Edmonton Zone ED's began dispensing these kits in 2016. The objectives of this study are to assess the trends in THN kit distribution from these sites in 2016 and 2017. Methods: The Edmonton Zone is a health region that comprises eleven tertiary, urban community and rural community ED's. THN kits in Edmonton Zone ED's were distributed through Pyxis, an automated medication dispensing and tracking system. Pyxis data for THN kits in 2016 and 2017 was extracted for each Edmonton Zone ED and the raw numbers and trends were examined. The National Ambulatory Care Reporting System database was also analyzed to determine the number of opioid related visits to Edmonton Zone ED's over that same time period. Results: A total of 686 THN kits in the Edmonton Zone were distributed over 2016 and 2017. The two tertiary centers distributed 502 kits, while the urban and rural community emergency departments collectively distributed 184 kits. Comparing 2016 (n = 245) to 2017 (n = 441), there was an 80% overall increase in the number of kits distributed, with tertiary center ED's dispensing 92% more kits, urban community ED's 51% more and rural ED's 63% more. Over the same time period, the number of opioid related visits increased in tertiary center ED's by 78%, in urban community sites by 26%, and in rural ED's by 67%. Almost all ED's increased their THN kit distribution from year to year, though there was one urban community site that dispensed fewer kits in the second year of the program. Conclusion: Edmonton Zone ED's dispensed 686 THN kits over two calendar years. Almost every ED distributed more kits in 2017 than 2016, which likely reflects successful uptake of this harm reduction intervention by frontline ED staff. However, there is still evidence of some imbalance in THN kit allocation as the percent increase in kits distributed varied widely based on the type of ED. This data can be used to pinpoint areas in the Edmonton Zone where barriers to THN access may still exist and guide continued quality improvement interventions to increase distribution and education.

Introduction: The quick Sepsis-related Organ Failure Assessment (qSOFA) score was developed to provide clinicians with a quick assessment for patients with latent organ failure possibly consistent with sepsis at high-risk for mortality. With the clinical heterogeneity of patients presenting with sepsis, a Bayesian validation approach may provide a better understanding of its clinical utility. This study used a Bayesian analysis to assess the prediction of hospital mortality by the qSOFA score among patients with infection transported by paramedics. Methods: A one-year cohort of adult patients transported by paramedics in a large, provincial EMS system was linked to Emergency Department (ED) and hospital administrative databases, then restricted to those patients with an ED diagnosed infection. A Bayesian binomial regression model was constructed using Hamiltonian Markov-Chain Monte-Carlo sampling, normal priors for each parameter, the calculated score, age and sex as the predictors, and hospital mortality as the outcome. Discrimination was assessed using posterior predictions to calculate a “Bayesian” C statistic, and calibration was assessed with calibration plots of the observed and predicted probability distributions. The independent predictive ability of each measure was tested by including each component measure (respiratory rate, Glasgow Coma Scale, and systolic blood pressure) as continuous predictors in a second model. Results: A total of 9,920 patients with ED diagnosed infection were included. 264 (2.7%) patients were admitted directly to the ICU, and 955 (9.6%) patients died in-hospital. As independent predictors, the probability of mortality increased as each measure became more extreme, with the Glasgow Coma Scale predicting the greatest change in mortality risk from a high to low score; however, no dramatic change in the probability supporting a single decision threshold was seen for any measure. For the calculated score, the C statistic for predicting mortality was 0.728. The calibration curve had no overlap of predictions, with a probability of 0.5 (50% credible interval 0.47-0.53) for patients with a qSOFA score of 3. Conclusion: Although no single decision threshold was identified for each component measure, a calculated qSOFA score provides good prediction of mortality for patients with ED diagnosed infection. When validating clinical prediction scores, a Bayesian approach may be used to assess probabilities of interest for clinicians to support better clinical decision making. Character count 2494

Introduction: In-hospital cardiac arrest (IHCA) most commonly occurs in non-monitored areas, where we observed a 10min delay before defibrillation (Phase I). Nurses (RNs) and respiratory therapists (RTs) cannot legally use Automated External Defibrillators (AEDs) during IHCA without a medical directive. We sought to evaluate IHCA outcomes following usual implementation (Phase II) vs. a Theory-Based educational program (Phase III) allowing RNs and RTs to use AEDs during IHCA. Methods: We completed a pragmatic before-after study of consecutive IHCA. We used ICD-10 codes to identify potentially eligible cases and included IHCA cases for which resuscitation was attempted. We obtained consensus on all data definitions before initiation of standardized-piloted data extraction by trained investigators. Phase I (Jan.2012-Aug.2013) consisted of baseline data. We implemented the AED medical directive in Phase II (Sept.2013-Aug.2016) using usual implementation strategies. In Phase III (Sept.2016-Dec.2017) we added an educational video informed by key constructs from a Theory of Planned Behavior survey. We report univariate comparisons of Utstein IHCA outcomes using 95% confidence intervals (CI). Results: There were 753 IHCA for which resuscitation was attempted with the following similar characteristics (Phase I n = 195; II n = 372; III n = 186): median age 68, 60.0% male, 79.3% witnessed, 29.7% non-monitored medical ward, 23.9% cardiac cause, 47.9% initial rhythm of pulseless electrical activity and 27.2% ventricular fibrillation/tachycardia (VF/VT). Comparing Phases I, II and III: an AED was used 0 times (0.0%), 21 times (5.6%), 15 times (8.1%); time to 1st rhythm analysis was 6min, 3min, 1min; and time to 1st shock was 10min, 10min and 7min. Comparing Phases I and III: time to 1st shock decreased by 3min (95%CI -7; 1), sustained ROSC increased from 29.7% to 33.3% (AD3.6%; 95%CI -10.8; 17.8), and survival to discharge increased from 24.6% to 25.8% (AD1.2%; 95%CI -7.5; 9.9). In the VF/VT subgroup, time to first shock decreased from 9 to 3 min (AD-6min; 95%CI -12; 0) and survival increased from 23.1% to 38.7% (AD15.6%; 95%CI -4.3; 35.4). Conclusion: The implementation of a medical directive allowing for AED use by RNs and RRTs successfully improved key outcomes for IHCA victims, particularly following the Theory-Based education video. The expansion of this project to other hospitals and health care professionals could significantly impact survival for VF/VT patients.

Introduction: Drones are already being used in medicine. They are employed to transport blood products and laboratory samples in rural and remote areas and they are increasingly being tested to deliver external defibrillators outside the hospital to patients with cardiac arrest. As this technology rapidly develops and attracts the attention of the scientific community, we present a rapid systematic review protocol that aims to synthesize the scientific evidence that has tested the use of drones to provide emergency medical care. Methods: A search strategy incorporating the concepts of ‘drone’ and ‘emergency medicine’ was launched in 52 bibliographic databases, including CINAHL and PubMed. Using the artificial intelligence module included in DistillerSR, a reviewer completed the first screening phase by reading the title and abstract of the retrieved articles. To be included, articles had to report empirical research projects that tested the potential uses of drones to improve the quality and accessibility of emergency medical care. These selection criteria were applied to the full text of the included articles during the second screening phase by a single reviewer. The results of these two screening phases will be validated by a second independent reviewer. The bibliography of included studies, relevant scientific journals and literature reviews will be manually searched for relevant articles. Results: The search strategy retrieved 1809 articles, of which 22 met our inclusion criteria in the first and second screening phases. Of these, one study used an empirical research design (qualitative interviews) to evaluate the usefulness of drones in emergency medicine, 17 used simulations or scenarios, and four were comprehensive literature reviews on the use of drones to provide healthcare. The final review will synthesize evidence related to the use of drones in emergency medicine and its impact on emergency medical services: nature of the emergency situation (cardiac arrest, blood transfusion), type of drone (fixed wing, quadcopter), tasks performed by drones (transport, surveillance), improvement in access or quality of care (patient's health, time saved in providing services). Conclusion: Drone technology is evolving rapidly and the indications for its use in providing emergency care is increasing. This rapid systematic review will focus on scientific studies aimed at testing the effectiveness of drones to improve the quality and access to emergency medical care.

Introduction: Patient assessment is a fundamental feature of non-emergency community paramedicine (CP) home visit programs. In the absence of a recognized standard for CP assessment, current assessment practices in CP programs are unknown. Without knowing what community paramedics are assessing, it is difficult to ascertain what should be included in patient care plans, whether interventions are beneficial, or whether paramedics are meeting program objectives. Our objective was to summarize the content of assessment instruments used in CP programs in order to describe the state of current practice. Methods: We performed an environmental scan of all CP programs in Ontario, Canada, and employed content analysis to describe current assessment practices in CP home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. Findings were compared at the domain and sub-domain of the ICF. Results: Of 54 paramedic services in Ontario, 43 responded to our request for information. Of 24 services with CP home visit programs, 18 provided their intake assessment forms for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Overall, most assessments included some content from each of the domains outlined in the ICF, including: Impairments of Body Functions, Impairments of Body Structures, Activity Limitation and Participation, and Environmental Factors. At the sub-domain level, only assessment of Impairments of the Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems appeared in all assessments. Few CP home visit program assessments covered most ICF sub-domain categories and many items classified to specific categories were included in only a few assessments. Conclusion: CP home visit programs complete multi-domain assessments as part of patient intake. The content of CP assessments varied across Ontario, which suggests that care planning and resources may not be consistent. Current work on practice guidelines and paramedic training can build from descriptions of assessment practices to improve quality of care and patient safety. By identifying what community paramedics assess, evaluation of the quality of CP home visit programs and their ability to meet program objectives can be improved and benchmarks in patient care can be established.

Introduction: Elderly patients with comorbid illness have poor meaningful recovery after out of hospital cardiac arrest. Many elderly patients decide that if they have a cardiac arrest, they would want not want resuscitation. In Ontario, prehospital personnel must provide resuscitation to all patients regardless of previously stated wishes or legal documentation unless they are presented a Ministry of Health mandated ‘Do Not Resuscitate’ Confirmation Form (MOH-DNRCF). This study aimed to evaluate the awareness of this form as well as any barriers to its completion. Methods: Patients over 70 years of age presenting to the Emergency Department were approached to complete a short survey about their wishes regarding resuscitation, awareness of the MOH-DNRCF, as well as any barriers to completion. Standard demographic variables were also collected. Patients, with critical illness, with severe dementia, a language barrier or from a nursing home were excluded. The primary outcome was awareness of the MOH-DNRCF. Standard descriptive statistics were summarized using median [IQR] and simple proportions. Results: Preliminary data of 96 patients has been collected. The median [IQR] age of patients recruited was 81 [75-88] years and 54% were female. 49/96 (51%) have wishes to not be resuscitated in the event of cardiac arrest and of those 42 (86%) are not aware of the existence of the MOH-DNRCF. Of the 7 patients who were aware of the form only 1 had completed one. Barriers to completion included the patient being unsure where to access the form and difficulty in discussing the topic. Conclusion: The majority of patients with wishes to be DNR are unaware of the MOH-DNRCF. This has severe repercussions as, in the event of an out of hospital cardiac arrest, these patients would be resuscitated by prehospital care providers. Strategies to increase awareness of the form as well as strategies to increase ease of access should be considered to avoid resuscitation that is against patient wishes.

Innovation Concept: Residents bear an enormous burden of responsibility for patient care which can lead to stress and mental exhaustion, especially in the face-paced and acute environment of emergency medicine (EM). In addition to numerous demands faced by EM residents, being a member of a geographically distributive residency program presents many unique challenges from a support and wellness perspective. To address these issues we sought to implement a video conferenced peer support network in hopes to foster wellness in the NOSM Family Medicine/EM program, where learners are commonly separated for training. Methods: Participants completed a pre-pilot questionnaire that strongly showed interest for this type of novel network. Furthermore residents conveyed that they are reluctant to access formal services and commonly rely on co-residents for support. This pilot program intends to decrease barriers that geography and stigma create that negatively hinder seeking support throughout medical training. Keeping the network small, consisting of only co-residents maintains a collegial and confidential environment that enables colleagues to provide relevant help to one another. Offering this outlet allows the opportunity to debrief and share unique experiences, which can lead to improved knowledge and wellbeing. Curriculum, Tool or Material: Informal, co-resident run and easy to access sessions are held twice monthly and average one hour in length. Discussion topics commonly include residency issues, difficult patient encounters and challenging situations. These sessions are conducted via video conferencing making them easily accessible from a distance and also from a comfortable and convenient environment of the participants choosing. Residents have commented that this is a helpful platform to discuss important issues while providing and safe and confidential resource to help cope with residency challenges. Conclusion: Further data analysis is underway as we are in the initial stages of implementing the program. In the final stages (April 2018) a pending post-pilot questionnaire will be interpreted to explore barriers, limitations and to determine the role of the network going forward. If found to be effective it is something that can be implemented and adapted for future residents. Other programs can use this feasible model to increase wellness and foster the same supportive environment among residents, especially those separated geographically from peers who may benefit most.

Introduction: The number of seniors presenting to emergency departments after a fall is increasing. Head injury concerns in this population often leads to a head CT scan. The CT rate among physicians is variable and the reasons for this are unknown. This study examined the role of patient characteristics and country of practice in the decision to order a CT. Methods: This study used a case-based survey of physicians across multiple countries. Each survey included 9 cases pertaining to an 82-year old man who falls. Each case varied in one aspect compared to a base case (aspirin, warfarin, or rivaroxaban use, occipital hematoma, amnesia, dementia, and fall with no head trauma). For each case, participants indicated how “likely” they were to order a head CT scan, measured on a 100-point scale. A response of 80 or more was defined a priori as ‘likely to order a CT scan’. The survey was piloted among emergency residents for feedback on design and comprehension, and was published in French and English. Recruitment was through the Canadian Association of Emergency Physicians, Twitter and CanadiEM. For each case we compared the proportion of physicians who were ‘likely to scan’ with relative to the base case. We also compared the proportion of participants who were ‘likely to scan’ each case in the USA, UK and Australia, relative to Canada. Results: Data was collected from 484 respondents (Canada-308, USA-64, UK-67, Australia-27, and 18 from other countries). Social media distribution limited our ability to estimate of the response rate. Physicians were most likely to scan in the anticoagulation cases (90% likely to order a scan compared to 36% for the base case (p = <0.001)). Other features associated with increased scans were occipital hematoma (48%), multiple falls (68%), and amnesia (68%) (all p < 0.005). Compared to Canada, US physicians were more likely to order CT scans for all cases (p = <0.05). Compared to Canada, UK physicians were significantly less likely to order CT for patients in every case except in the patient with amnesia. Finally, Australian physicians differed from Canada only for the occipital hematoma case where they were significantly more likely to order CT scan. Conclusion: Anticoagulation, amnesia and a history of multiple falls appear to drive the ordering a head CT scan in elderly patients who had fallen. We observed variations in practice between countries. Future clinical decision rules will likely have variable impact on head CT scan rates depending on baseline practice variation.

Introduction: Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled low-dose methoxyflurane) initiated by triage nurse. Methods: We performed a prospective, observational study in the emergency department at Grenoble Alpes University Hospital (Grenoble, France) between October 2017 and April 2018. Non severe adult trauma patients with a numerical pain rating scale (NRS) score ≥4 and receiving MEOF were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤3 at 15min post-administration. Pain intensity was measured for 60 min as well as during radiography. Data on adverse events and satisfaction were also recorded. Data are presented as median [interquartile (IQR)] and were compared using non parametric tests. Results: A total of 200 adult patients were included (age: 32 [IQR: 23–49] years; 126 men (63%)). Patients presented at triage with a pain score of 7 [IQR: 6-8]. Sixty-six patients (33%) reported an NRS score ≤3 at 15 min post-administration. The time required to achieve a decrease of at least 2 points in the NRS score was 10 [IQR 5–20] min. The pain intensity was 4 [IQR: 2–5] before radiography and 4 [IQR: 2–6] during radiography. Adverse events were frequent (n = 128, 64%), mainly dizziness. No serious adverse events were reported and 89% of minor adverse events resolved at one hour. Both patients and health care providers reported good levels of satisfaction. Conclusion: The administration of a nurse-driven multimodal analgesia protocol combining paracetamol, oxycodone, and low-dose methoxyflurane was feasible on triage. It rapidly produced long-lasting analgesia in adult trauma patients.

Introduction: Health disparities between racial and ethnic groups have been well documented in Canada, the United States, and Australia. Despite evidence that differences in emergency department (ED) care based on patient race and ethnicity exist, there is a lack of scientific reviews in this important area. The objective of this review is to provide an overview of the literature on the impact of patient race and ethnicity on ED care. Methods: A scoping review guided by the framework described by Arksey and O'Malley was undertaken. This approach was taken because it was best suited to the goal of providing an overview of all of the literature, given the broad nature of the topic. All studies with primary outcomes considering the impact of patient race and ethnicity on “throughput” factors in the ED as defined by Asplin et al., were considered. Outcomes considered included triage scores, wait times, analgesia, diagnostic testing, treatment, leaving without being seen, and patient experiences. Literature from Canada, the United States, Australia, and New Zealand was considered. A database search protocol was developed iteratively as familiarity with the literature developed. Inclusion and exclusion decisions were made using an established model. Results: The original search yielded 1157 citations, reduced to 453 after duplicate removal. 153 full texts were included for screening, of which 85 were included for final data extraction. Results indicate there is evidence that minority racial and ethnic groups experience disparities in triage scores, wait times, analgesia, treatment, diagnostic testing, leaving without being seen, and subjective experiences. Authors’ suggested explanations for these disparities can be placed in the following categories: (1) communication differences; (2) conscious or unconscious bias; (3) facility and resource factors in hospitals with higher minority presentation rates; and (4) differences in clinical presentations. Conclusion: This scoping review provides an overview of the literature on the impacts of race and ethnicity on ED care. As disparities have been shown to exist in numerous contexts, further research on the impact of race and ethnicity in ED care is warranted, especially in the Canadian literature. Such explorations could aid in the informing and creation of policy, and guide practice.

Introduction: Choosing Wisely Canada guidelines suggest that in the absence of red flags or clinical indicators suggestive of serious underlying conditions, physicians should not order radiological images for patients presenting with non-specific low back pain, and current recommendations do not endorse routine prescribing of opioids for this condition. The objective of this study was to determine how many patients presenting to the ED with non-traumatic low back pain have spinal imaging and how many are discharged home on opioids. Methods: We conducted a retrospective medical record review for adult (>17 years) patients presenting to an academic tertiary care ED with non-traumatic low back pain from April 1st 2014 to March 31st 2015 (pre-guideline) and April 1st 2017 to March 31st 2018 (post-guideline). Patients were excluded if they were >70 years old, were not discharged home, had a traumatic injury, features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, first episode of low back pain over 50 years of age, abnormal reflexes, loss of motor strength or loss of sensation in the legs. Results: 1060 (545 pre-guideline, 515 post-guideline) were included. Mean (SD) age was 39.6 (12.3) years and 549 (51.8%) were female. Pre-guideline, 45 (8.3%) patients had spinal imaging, compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% CI: −2.6% to 4.0%). Of the 84 (7.9%) patients who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline, compared to 10 (25.6%) patients post-guideline. The proportion of patients discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines (40.9% vs. 11.1%; Δ29.8%; 95% CI: 24.8% to 34.7%). Conclusion: Choosing Wisely Canada guidelines did not appear to alter the rate of imaging for patients presenting to the ED with non-traumatic low back pain. Overall the rate of spinal imaging was lower than expected. The proportion of patients who were discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines, however we don't know if this represents an overall trend in the reduction of opioid prescribing, or a specific change in practice related to the ED management of low back pain.

Introduction: Little is known about the variety of roles volunteers play in the emergency department (ED), and the potential impact they have on patient experience. The objective of this scoping review was to identify published and unpublished reports that described volunteer programs in EDs, and determine how these programs impacted patient experiences or outcomes. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. A grey literature search was also conducted (Web of Science, ProQuest, Canadian Business and Current Affairs Database ProQuest Dissertations and Theses Global). Two reviewers independently screened titles and abstracts, reviewed full text articles, and extracted data. Results: The search strategy yielded 4,589 potentially relevant citations. After eliminating duplicate citations and articles that did not meet eligibility criteria, 87 reports were included in the review. Of the included reports, 18 were peer-reviewed articles, 6 were conference proceedings, 59 were magazine or newspaper articles, and 4 were graduate dissertations or theses. Volunteer activities were categorized as non-clinical tasks (e.g., provision of meals/snacks, comfort items and mobility assistance), navigation, emotional support/communication, and administrative duties. 52 (59.8%) programs had general volunteers in the ED and 35 (40.2%) had volunteers targeting a specific patient population, including pediatrics, geriatrics, patients with mental health and addiction issues and other vulnerable populations. 20 (23.0%) programs included an evaluative component describing how ED volunteers affected patient experiences and outcomes. Patient satisfaction, follow-up and referral rates, ED and hospital costs and length of stay, subsequent ED visits, medical complications, and malnutrition in the hospital were all reported to be positively affected by volunteers in the ED. Conclusion: This scoping review demonstrates the important role volunteers play in enhancing patient and caregiver experience in the ED. Future volunteer engagement programs implemented in the ED should be formally described and evaluated to share their success and experience with others interested in implementing similar programs in the ED.

Introduction: Emergency department (ED) care allows for the rapid assessment of patient concerns, but often leads to tests being performed that are not finalized or reviewed prior to patients leaving the ED. The follow-up for these tests pending at discharge (TPADs), most commonly final diagnostic imaging (DI) reports and microbiology cultures, is a major medico-legal concern for ED providers and significant safety concern for patients. We therefore performed a systematic review of the literature to identify existing ED quality assurance (QA) processes to address TPADs relating to final DI reports and microbiology cultures. Methods: Comprehensive literature searches were developed with a medical librarian and conducted in Ovid Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL from inception through May 8, 2018. Studies were included if they described an intervention or program designed to follow-up relevant ED TPADs, and excluded if they pertained to communication between departments or clinicians only rather than with patients. Study selection was performed independently by two reviewers in two steps (title and abstract review, then full-text review), with all discrepancies resolved by consensus with a senior reviewer. The primary outcome was the description of any QA process to follow-up on TPADs and secondary outcomes included quantifiable results of successful interventions or programs. Results: From the 11,685 articles identified, 58 were selected for full-text review, and 12 met eligibility criteria. In the included studies, the responsibility for following up on TPADs was owned by different members of the care team (e.g., ED physicians, nurses or radiologists) and recorded in a variety of ways (e.g., electronic medical record, paper chart, system designed for TPADs). Follow-up pathways with variable standardization were described, ranging from dedicated assignment for TPAD duties with protected/remunerated time to do so, to follow-up completion done by the first clinician to receive the TPAD result. Studies that evaluated their QA process implementation found that more patients were notified of abnormal test results, follow-up times decreased, and fewer unnecessary antibiotics were used. Conclusion: A variety of QA processes have been implemented to follow up on ED TPADs in terms of personnel involved, charting and logistics, and when evaluated, they have improved patient care.

Introduction: The Canadian Triage and Acuity Scale (CTAS) identifies the level of urgency when patients arrive to the Emergency department (ED). Sepsis is challenging to recognize and is associated with significant mortality (30 to 50%). The integration of the COP criteria allows for earlier detection and management of sepsis.The CTAS's validity and reliability are debated. The NEWS score has been suggested to allow a timely recognition of sepsis.Objectives:To describe patient orientation at ED triage with the NEWS vs. the CTAS and COP criteria and to identify the NEWS's ability to detect patients who will require admission to critical care. Methods: Design: A retrospective cohort study of ED 225 patients (January-November 2018) is was constituted. Participants: Patients were included if they were aged ≥18, consulting to the ED, presented one of the 32 diagnoses included in the CMI-10. Measurements: Retained variables are sex, age, CTAS score and level of care. The NEWS score was calculated from triage vital signs. Main outcome was Patient orientation after ED triage using CTAS vs the NEWS score. Descriptive statistics to determine patient orientation based on the NEWS and CTAS were performed. Fisher tests (α = 0.05) were used to assess a possible association between both triage scales and identify the NEWS's ability to detect patients who will require admission to critical care during. Sample size was calculated in order to detect a 15% difference between actual orientation and theoretical orientation based on the NEWS. Results: The retained cohort (45% men) were aged 66 ± 21 years. 67% were admitted, 14% of which to a critical care unit. Average length of hospital stay was 6.3 ± 7.8 days. Primary objective: patient orientation after triage using CTAS vs the NEWS was: 29% vs. 18% for high risk patients; 2% vs. 67% for low risk patients (p < 0.0001), respectively. Secondary objective: Among patients with stable NEWS score, 53% were admitted to hospital among patients with medium NEWS score, 9% of patients were admitted to the critical care (p = 0.0003) Conclusion: Patient orientation after ED triage using CTAS vs the NEWS is significantly different. The NEWS alone does not seem to be able to detect patients who will require admission to critical care. Future studies exploring an aggregate scoring system combining the NEWS and CTAS could be performed to determine if sepsis recognition and patient orientation can be improved

Introduction: Effective communication to develop a shared understanding of patient/caregiver (P/C) expectations is critical during emergency department (ED) encounters. However, there is limited research examining the use of communication tools of P/C expectations to improve communication in the ED. The objective of this study was to examine satisfaction with a patient expectations questionnaire, known as the PrEPP tool, and its impact on communication and management of patients in the ED. Methods: The PrEPP tool collected P/C expectations over 3 phases of the study. In phase1, the PrEPP tool was distributed to all P/Cs (CTAS score of 2 to 5) in four EDs in Nova Scotia. In phase 2 the PrEPP tool was refined to a 5-item questionnaire. In phase 3 the PrEPP tool was re-implemented over a six-month period. Follow-up surveys were distributed to P/Cs via email (phase 1, 3) and HCPs on iPads in the ED (phase 3) to determine the impact of the tool on communication and management of patients. Entries were compiled on a REDCap database and descriptive statistics were used to analyze responses related to satisfaction.The PrEPP tool collected P/C expectations over 3 phases of the study. In phase1, the PrEPP tool was distributed to all P/Cs (CTAS score of 2 to 5) in four EDs in Nova Scotia. In phase 2 the PrEPP tool was refined to a 5-item questionnaire. In phase 3 the PrEPP tool was re-implemented over a six-month period. Follow-up surveys were distributed to P/Cs via email (phase 1, 3) and HCPs on iPads in the ED (phase 3) to determine the impact of the tool on communication and management of patients. Entries were compiled on a REDCap database and descriptive statistics were used to analyze responses related to satisfaction. Results: In Phase 1, 11418 PrEPP tools and 147 surveys (29% response rate) were collected from January-June 2016. The majority of P/Cs found the PrEPP questionnaire easy to complete (95.9%) and felt HCPs met their expectations (87.1%). In Phase 3, 951 P/C (31.1% response rate) and 128 HCP surveys were collected. Of P/C respondents 45.9% felt PrEPP helped to communicate expectations, while 49.7% said that they would like to use it on future ED visits. The majority of P/C respondents (75.4%) indicated their expectations were met during their visit to the ED. Of those whose expectations were not met, 69% felt their expectations were not discussed. The majority of HCP respondents (90.4%) indicated they used the PrEPP tool at least sometimes. Also, 78.4% said it influenced patient communication and 42% indicated the tool influenced management of patients at least sometimes. Conclusion: Obtaining expectations early in the patient encounter may provide opportunities for improved communication in the ED. P/Cs found the PrEPP tool easy to use to communicate their expectations and HCPs felt it influenced communication and management of patients in the ED. Further qualitative thematic analysis is needed to explore how the PrEPP tool impacted ED visits.

Introduction: The RAPID RIP clinical decision aid was developed to identify patients at high-risk for acute aortic syndrome (AAS) who require investigations. It stratifies patients into low (no further testing) intermediate (D-dimer if no alternative diagnosis) and High risk (Computed tomography (CT) aorta). Our objectives were to assess its impact on: a) Documentation of high risk features/pre test probability for AAS b) D-dimers ordered c) CT ordered and d) Emergency department length of stay. Methods: We conducted a prospective pilot before/after study at a single tertiary-care emergency department between August and September 2018. Consecutive alert adults with chest, abdominal, flank, back pain or stroke like symptoms were included. Patients with pain >14 days or secondary to trauma were excluded. Results: We enrolled 1,340 patients, 656 before and 684 after implementation, including 0 AAS. Documentation of pre test probability assessment increased (0% to 3%, p < 0.009) after implementation. The proportion who had D-dimer performed increased (5.8% to 9.2% (p < 0.2), while the number of CT to rule out AAS remained stable (0.59% versus 0.58%; p = 0.60). The mean length of ED stay was stable (2.31+/−2.0 to 2.28+/−1.5 hours; p = 0.45) and slightly decreased in those with pre test probability documented (2.1+/−1.4 p < 0.09). The specificity of the decision aid for CT was 100%( 95%CI 71.5- 100%). If it were applied to all patients with high-risk clinical features of AAS the specificity would be 92.6% (95%CI 90.1-94.6%). Conclusion: Implementation of the RAPID RIP increased documentation of important high-risk features for AAS. The RAPID RIP strategy increased use of D-dimer without increasing the number of CT and had a trend towards decreased length of stay.

Introduction: Patients with chronic non-cancer pain (CNCP) and opioid-use disorders make up a category of patients who present a challenge to emergency department (ED) providers and healthcare administrators. Their conditions predispose them to frequent ED utilization. This problem has been compounded by a worsening opioid epidemic that has rendered clinicians apprehensive about how they approach pain care. A systematic review has not yet been performed to inform the management of CNCP patients in the ED. As such, the purpose of this project was to identify and describe the effectiveness of interventions to reduce ED visits for high-utilizers with CNCP. Methods: Included participants were high-utilizers presenting with CNCP. All study designs were eligible for inclusion if they examined an intervention aimed at reducing ED utilization. The outcomes of interest were the number of ED visits as well as the amount and type of opioids prescribed in the ED and after discharge. We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, Web of Science, and the grey literature from inception to June 16, 2018. Two independent investigators assessed articles for inclusion following PRISMA guidelines. Risk of bias will be assessed using the Cochrane ROBINS-I and RoB 2 tools for non-randomized and randomized trials, respectively. Results: Following review, 14 of the 5,018 identified articles were included for analysis. These articles assessed a total of 1,670 patients from both urban and rural settings. Interventions included pain protocols or policies (n = 5), individualized care plans (n = 5), ED care coordination (n = 2), a chronic pain management pathway (n = 1), and a behavioural health intervention (n = 1). Intervention effects trended towards the reduction of both ED visits and opioid prescriptions. The meta-analysis is in progress. Conclusion: Preliminary results suggest that interventions aimed at high-utilizers with CNCP can reduce ED visits and ED opioid prescription. ED opioid-restriction policies that sought to disincentivize drug-related ED visits were most successful, especially when accompanied by an electronic medical record (EMR) alert to ensure consistent application of the policy by all clinicians and administrators involved in the care of these patients. This review was limited by inconsistencies in the definition of ‘high-utilizer’ and by the lack of high-powered randomized studies.

Introduction: Influenza is a preventable infectious disease that causes a yearly burden to Canada. While an influenza vaccine is available free of charge in most provinces, uptake is below target rates. 15% of Canadians who did not get the influenza vaccine reported that they “didn't get around to it”; this presents an opportunity to combine the task of influenza prevention with the logistical issue of another health system challenge: escalating emergency department (ED) wait times. At the Queen Elizabeth II Health Sciences Centre (QEII) in Halifax, NS, average wait time is 4.6 hours. Offering the influenza vaccine during this time could increase convenient access to health services, and ultimately, improve vaccination rates. Methods: This observational, cross-sectional design study is currently in progress. It aims to gauge public interest, health care provider (HCP) support, perceived barriers and perceived facilitators to influenza vaccine availability at the QEII ED. Data is being collected via short, anonymous, close-ended questionnaires over a 7-week period, set to end Dec 14, 2018. Client participants are a convenience sample of low-acuity (Canadian Triage and Acuity Scale score 4/5), adult clients who use the QEII ED during the study period, anticipated n = 150. Client questionnaires are completed, with the help of a research assistant, on an iPad that inputs data directly into a secure online data collection tool. The HCP group is a convenience sample of nurses, physicians and paramedics currently working in the QEII ED, anticipated n = 80. Questionnaires are available to HCPs either on paper outside the staff lounge, or online. Data is being collected via short, anonymous, close-ended questionnaires over a 7-week period, set to end Dec 14, 2018. Client participants are a convenience sample of low-acuity (Canadian Triage and Acuity Scale score 4/5), adult clients who use the QEII ED during the study period, anticipated n = 150. Client questionnaires are completed, with the help of a research assistant, on an iPad that inputs data directly into a secure online data collection tool. The HCP group is a convenience sample of nurses, physicians and paramedics currently working in the QEII ED, anticipated n = 80. Questionnaires are available to HCPs either on paper outside the staff lounge, or online. Results: Following completion of data collection, descriptive statistics, such as the frequency of support for ED influenza vaccination and the proportion of unvaccinated clients willing to receive the vaccine if available in the ED, will be calculated using IBM SPSS Statistics 25. This will provide meaningful data that can be used by the QEII to inform future program planning (i.e. should the influenza vaccine be made available in the ED). Conclusion: An ED vaccination program could add value to the hours clients spend waiting to be seen, and make ED care more cohesive. It is essential that clients and ED staff are approached prior to any new initiative; this study is one way we can lay the necessary groundwork for a public health program that would utilize patient “wait time” more effectively.