Introduction: Simulation is becoming widely adopted across medical disciplines and by different medical professionals. For medical students, emergency medicine simulation has been shown to increase knowledge, confidence and satisfaction. At the University of Ottawa Skills and Simulation Centre, third-year medical students participate in simulated scenarios common to Emergency Medicine (EM) as part of their mandatory EM clerkship rotation. This study aims to evaluate simulation as part of the EM clerkship rotation by assessing changes in student confidence following a simulation session. Methods: In groups of seven, third year medical students at the University of Ottawa completed simulation sessions of the following: Status Asthmaticus, Status Epilepticus, Urosepsis and Breaking Bad News. Student confidence with each topic was assessed before and after simulation with a written survey. Confidence scores pre- and post-simulation were compared with the Wilcoxon signed rank test. Results: Forty-eight third years medical students in their core EM clerkship rotation, between September 2017 and August 2018 participated in this study. Medical student confidence with diagnosis of status asthmaticus (N = 44, p = 0.0449) and status epilepticus (N = 45, p = 0.0011) increased significantly following simulation, whereas confidence with diagnosis of urosepsis was unchanged (N = 45, p = 0.0871). Treatment confidence increased significantly for status asthmaticus (N = 47, p = 0.0009), status epilepticus (N = 48, p = 0.0005) and urosepsis (N = 48, p < 0.0001). Confidence for breaking bad news was not significantly changed after simulation (N = 47, p = 0.0689). Conclusion: Simulation training in our EM clerkship rotation significantly increased the confidence of medical students for certain common EM presentations, but not for all. Further work will aim to understand why some simulation scenarios did not improve confidence, and look to improve existing scenarios.

Introduction: Patient satisfaction is an essential component of effective delivery of quality care in the emergency department (ED). Frequent reflection on current practices is required to detect areas in need of improvement. The Ontario Hospital Association (OHA) outlined five ‘Leading Practices’ (LPs) targeted to increase patient satisfaction in this setting. The ED volunteers are a group of individuals who have unique perspectives on ED practices that are unbiased by confounders affecting patients and staff. The goal of this study was to explore the unique perspectives of ED volunteers involving what they believe will improve the delivery of patient-centered care, as well as to examine to what extent Saskatoon EDs are embracing the principles outlined in the OHA LPs. Methods: A two-phase mixed methods approach, with a survey followed by interviews that allowed participants to expand on survey findings was used. The pool of 45 ED volunteers was extended the opportunity to participate resulting in 36 survey responses and 6 interviews. The 13 Likert-grade survey questions were generated to align to each of the LPs and allowed room for qualitative feedback. Interview questions were generated following 15 survey responses to expand on the LPs that were rated below average. Results: Analysis of responses identified inefficient ED processes leading to increased waiting times, inefficient patient location, inadequate signage, a lack of physical space, unclean environments, and a lack of staff and volunteer awareness regarding spiritual care and interpreter services, perceptions of received care by patients due to long wait times and level of cultural safety training of ED staff. Themes reduced from interviews yielded common themes such as patient frustration, disorganization, uncomfortable environment, overcrowding, prolonged wait times, and patient misconception of ED processes at Site 1. Themes common to Site 2 included organization, patient-friendly environment, patient misconception of ED processes, and prolonged wait times. Additionally, the volunteers suggested a plethora of interventions that could improve the current processes in Saskatoon's EDs to make them more patient friendly. Conclusion: Saskatoon EDs comply reasonably well to the OHA Leading practices. Surveying ED volunteers provides important insight into current practices and areas for improvement, and should be considered at other sites to improve adherence to the OHA LPs.

Introduction: Vast geography and low population density limit availability of specialized trauma and medical care in many areas of Ontario. As such, patients with severe illnesses often require a higher level of care than local facilities can provide and thus require an interfacility transfer to access tertiary or quaternary care. In Ontario, Ornge, a provincially run air ambulance, serves as the sole provider of air-based medical and critical care transport. Patient outcomes are impacted by the time to definitive care, yet little research about reasons for delay in interfacility transfer within Ontario has been conducted. This study aimed to identify causes of delay in interfacility transport by air ambulance in Ontario. Methods: Causes of delay were identified by manual chart review of electronic patient care records (ePCR). All emergent adult interfacility transfers for patients transported by Ornge between Jan. 1-Dec. 31, 2016 were eligible for inclusion. Patient records were flagged to be manually reviewed if they met one or more of the following criteria: 1) contained a standardized delay code; 2) the ePCR free text contained “delay”, “wait”, “duty-out”, or common misspellings therein; 3) were above the 75th percentile in total transport time; or 4) were above the 90th percentile in time to patient bedside, time spent at the sending hospital, or time to receiving facility. Each trip was categorized as having delays that fall into one or more of the following categories: time-to-sending delays, in-hospital delays, and time-to-receiving/handover delays. Results: Our search strategy identified 1,220 records for manual review and a total of 872 delays were identified. The most common delays cited included aircraft refuelling (234 delays); waiting for land EMS escort (144); and unstable patients requiring advanced care such as intubation, procedures, or transfusion (79). Other delays included handover or delays at the receiving facility (42); mechanical issues (36); dispatch-related issues (53); environmental hazards (43); staffing issues (47); and equipment problems (38). Conclusion: Some common causes of interfacility delay are potentially modifiable: better trip planning around refueling, and improved coordination with local EMS could impact many delayed interfacility trips in Ontario. Our analysis was limited by number and completeness of available records, and documentation quality. To better understand causes for delay, we would benefit from improved documentation and record availability.

Introduction: When a patient is incapable of making medical decisions for themselves, choices are made according to the patient's previously expressed, wishes, values, and beliefs by a substitute decision maker (SDM). While interventions to engage patients in their own advance care planning exist, little is known about public readiness to act as a SDM on behalf of a loved one. This mixed-methods survey aimed to describe attitudes, enablers and barriers to preparedness to act as a SDM, and support for a population-level curriculum on the role of an SDM in end-of-life and resuscitative care. Methods: From November 2017 to June 2018, a mixed-methods street intercept survey was conducted in Ottawa, Canada. Descriptive statistics and logistic regression analysis were used to assess predictors of preparedness to be a SDM and understand support for a high school curriculum. Responses to open-ended questions were analyzed using inductive thematic analysis. Results: The 430 respondents were mostly female (56.5%) with an average age of 33.9. Although 73.0% of respondents felt prepared to be a SDM, 41.0% of those who reported preparedness never had a meaningful conversation with loved ones about their wishes in critical illness. The only predictors of SDM preparedness were the belief that one would be a future SDM (OR 2.36 95% CI 1.34-4.17), and age 50-64 compared to age 16-17 (OR 7.46 95% CI 1.25-44.51). Thematic enablers of preparedness included an understanding of a patient's wishes, the role of the SDM and strong familial relationships. Barriers included cultural norms, family conflict, and a need for time for high stakes decisions. Most respondents (71.9%) believed that 16 year olds should learn about SDMs. They noted age appropriateness, potential developmental and societal benefit, and improved decision making, while cautioning the need for a nuanced approach respectful of different maturity levels, cultures and individual experiences. Conclusion: This study reveals a concerning gap between perceived preparedness and actions taken in preparation to be an SDM for loved ones suffering critical illness. The results also highlight the potential role for high school education to address this gap. Future studies should further explore the themes identified to inform development of resources and curricula for improved health literacy in resuscitation and end-of-life care.

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.

Introduction: Transition to the attending physician role and onboarding at a new workplace are often stressful. Effective initiation is important to individuals as well as departments, hospitals and universities wishing to retain valuable staff. Our aim was to learn about early experiences from the perspective of new staff and apply these findings to develop a new onboarding program. Methods: Following a pilot study of individual interviews, we surveyed and conducted focus group interviews with all attending physicians who had joined our dual site, urban, academic emergency department within three years. We used a mixed quantitative and qualitative approach to collect and analyze data. We applied the data to develop a new needs-based formal onboarding program. Results: 24/36 participated in the survey, 22/36 in focus groups. 95% were 30-39 years old. Newcomers described the existing orientation as too brief, non-specific, and missing essential elements. We identified six onboarding themes: (1)clinical protocols and reference documents, (2)graduated responsibilities, (3)mentorship, (4)relationship building, (5)department structure and culture, and (6)emotions. We formed a committee to develop and implement these initiatives: (1)a new online platform enables easy access to clinical care and orientation documents, (2)a formal mentorship program matches each newcomer with 2 mentors to coach towards goals, navigate department structure and culture, and provide perspective to mitigate strong emotions, (3)adjusting shift and teaching assignments allows newcomers to ease into clinical and academic responsibilities, and (4)our next priority is to improve clarity around academic opportunities, expectations, and advancement. Conclusion: New emergency physicians are highly engaged and provided many insights on their orientation experiences. Using mixed methods, we identified six themes to guide the design and implementation of a program to promote successful integration of newcomers.

Introduction: Unique weather patterns on March 16th, 2017 led to 3 times the number of emergency department (ED) visits due to fall-injuries (FIs) on snow or ice compared to winter averages. The objective of the study was to identify weather-dependent differences in demographics, length-of-stay (LOS) predictors, and volume of ED presentations for winter FIs. We placed emphasis on Chinook phenomenon (rapid freeze-thaw cycles) common east of the Rocky Mountains. Methods: Patients with extremity injury due to fall on snow or ice were identified from the Alberta Health Services ED database from November 1st 2013 to March 31st 2018. We conducted regressions, chi-square analysis, bivariate correlations, and t-tests to identify differences in post-Chinook, high-volume, and regular winter patient cohorts. High-volume dates included any date with more than 25 FI presentations, representing a 400% increase from the daily average of 5. Results: We identified 3478 patients, with females more likely to present, X2 (1, N = 3480) = 443.266, p < 0.001, making up 67.8% of the total cohort. Mean age was 48.2 (SD ± 19.9) in all patients, and 48.4 (SD ± 20.0) among the post-Chinook cohort. Looking at ED LOS in the full patient cohort, age over 65 predicted longer ED LOS (mean = 4.23, SD ± 3.06) compared to younger age groups (mean = 3.42, SD ± 2.39), t(3478) = -7.37, p < 0.001]. Patients with fractures to the wrist or hand had shorter ED LOS (mean = 2.50, SD ± 5.83) than those without (mean = 10.95, SD ± 92.54), t(3478) = 2.64, p = 0.008. Among admitted patients, results were similar, with elevated inpatient LOS for patients over the age of 65 (mean = 171.71, SD ± 508.35) compared to younger patients (mean = 45.45, SD ± 39.53), t(3478) = −3.41, p = 0.001. Patients with radius fractures had shorter LOS (mean = 61.87, SD ± 210.37) compared to those without (mean = 288.83, SD ± 632.29), t(3478) = 3.87, p < 0.001. With respect to volume and weather, night-freezing events (below-freezing temperatures the preceding day, followed by freezing temperatures prior to 0600 hours the following day) were more likely to result in high FI volume (OR, 8.08; 95% CI, 5.14, 12.07; p < 0.001) as were recent Chinook events (OR, 1.39; 95% CI, 1.06, 1.81; p = 0.017). Conclusion: Chinook-induced meteorological mass-casualty events can be severe, but do not target populations distinct from winter averages. They can be predicted based on forecasted weather variations and should be considered for population-level alerts utilizing cellular technology.

Introduction: Emergency department (ED) staff carry a high risk for the burnout syndrome of increased emotional exhaustion, depersonalization and decreased personal accomplishment. Previous research has shown that task-oriented coping skills were associated with reduced levels of burnout compared to emotion-oriented coping. ED staff at one hospital participated in an intervention to teach task-oriented coping skills. We hypothesized that the intervention would alter staff coping behaviors and ultimately reduce burnout. Methods: ED physicians, nurses and support staff at two regional hospitals were surveyed using the Maslach Burnout Inventory (MBI) and the Coping Inventory for Stressful Situations (CISS). Surveys were performed before and after the implementation of communication and conflict resolution skills training at the intervention facility (I) consisting of a one-day course and a small group refresher 6 to 15 months later. Descriptive statistics and multivariate analysis assessed differences in staff burnout and coping styles compared to the control facility (C) and over time. Results: 85/143 (I) and 42/110 (C) ED staff responded to the initial survey. Post intervention 46 (I) and 23(C) responded. During the two year study period there was no statistically significant difference in CISS or MBI scores between hospitals (CISS: (Pillai's trace = .02, F(3,63) = .47, p = .71, partial η2 = .02); MBI: (Pillai's trace = .01, F(3,63) = .11, p = .95, partial η2 = .01)) or between pre- and post-intervention groups (CISS: (Pillai's trace = .01, F(3,63) = .22, p = .88, partial η2 = .01); MBI: (Pillai's trace = .09, F(3,63) = 2.15, p = .10, partial η2 = .01)). Conclusion: We were not able to measure improvement in staff coping or burnout in ED staff receiving communication skills intervention over a two year period. Burnout is a multifactorial problem and environmental rather than individual factors may be more important to address. Alternatively, to demonstrate a measurable effect on burnout may require more robust or inclusive interventions.

Introduction: Qualitative research with emergency department (ED) patients in Alberta has revealed that some patients have limited understanding of the ED care process and that this increases the anxiety, frustration and confusion experienced throughout their visit. The objective of this study was to design, implement, and test the usefulness of a poster explaining the ED care process. Methods: As part of a stepped-wedge ED intervention trial in Alberta, a 4′ x 3′ poster portraying the patient ED care process was developed and posted in 15 study site waiting rooms. Trained research assistants approached patients in 3 urban ED waiting areas and invited them to complete a short paper-based survey on the acceptability and usefulness of the poster. Results are reported as proportions. Results: A total of 316 patients agreed to participate in this study. Approximately half of the participants were male and 60% were between the ages of 17 and 49. The majority of participants identified themselves as white (72%) and nearly half (49%) were accompanied by someone. A third (37%) of patients had read the wall poster prior to being approached to complete the survey. Most patients (62%) who had not read it prior to being approached hadn't noticed the poster or couldn't see it because of its location. Once patients reviewed the poster, the vast majority (92%) reported completely or largely understanding the information and most (84%) found it at least moderately helpful in preparing them for their ED journey. Approximately 45% of respondents agreed that they learned something new about the ED care process by reading the poster and 20% wanted additional information added to the poster; largely, wait time estimates (53% of responses). Conclusion: Placing posters in the ED is one method for equipping patients for their ED care process; however, this study revealed the potential limited utility of this engagement method by the small number of patients who noticed the poster and read the information. Location and content (e.g., time estimates) were identified as key factors for implementation. Condition-specific guides may need to supplement general ED process guides to better prepare patients for their individual ED journey and to actively engage them in their ED care.

Introduction: Patient engagement in health decision-making is an important research area within emergency medicine. Studies suggest that patients are often not highly engaged in care decisions, and may not be aware that there are decisions in which they can be involved. This study explored emergency physicians (EPs) perceptions of their patient engagement practices. Methods: As part of a stepped-wedge randomized controlled trial, an introductory seminar was held at 15 emergency department (ED) sites in Alberta. Seminars highlighted physician-patient communication and expectation gaps documented in local studies. As part of the seminar evaluation, EPs were asked to reflect on their engagement of patients in their practice. Descriptive results are reported. Results: A total of 114 EP surveys were returned. The majority of respondents were male (68%) and nearly 40% of respondents have practiced emergency medicine for 5 years or less. Less than half of the EPs (43%) reported always or usually asking their patients about their ED visit care expectations. Approximately one-third (32%) reported always or usually checking their patients’ understanding of management options (e.g., tests, treatments and/or procedures). Patients management preferences were always or usually elicited 24% of the time. Despite limited consistency in ascertaining patients’ preferences, 39% of EPs indicated that they always or usually considered their patients’ preferences when choosing a management plan. Half of the EPs (51%) reported that they always or usually involved their patients in decision-making. Yet, when asked whether other EPs involved their patients in decision-making, only 15% reported that they believed their fellow clinicians did this always or usually. On average, 68% of respondents believed their patients wanted to be completely or mostly involved in their ED and decision-making; however, 16% believed patients were actually completely or mostly involved in the ED care and decision-making. Conclusion: EPs agreed that patients want to be actively involved in their ED care decisions. Yet, their reflection on their own practice, and especially their perception of their colleagues’, highlight large gaps between physicians’ perception of what patients would like and what patients actually receive. Further research should explore these interactions in depth, understand what constrains EPs from involving patients and explore patient perceptions of these interactions.

Introduction: Variation in medication management and image ordering for HA presentation to emergency departments (ED) has been documented. This study examined benign HA (i.e., migraine, cluster, tension) management in order to identify the consistency and appropriateness of HA management in EDs in Alberta. Methods: Patients were identified by primary discharge diagnosis in the National Ambulatory Care Reporting System using ICD-10-CA codes for benign HA (G43, G44, R51). Patients presenting to study sites from January 1, 2017 to September 30, 2017 were eligible for inclusion, provided they were adults (≥18 years), were not transferred from another institution or directly admitted to a service, and had an active HA at presentation. One hundred eligible patients were randomly selected for chart review. Data were extracted on standardized forms. Preliminary data on 50 patients (n = 150) from three Edmonton study sites is presented. Results: Most patients arrived to the ED via personal transportation (93%) and were assigned a Canadian Triage and Acuity Scale (CTAS) score of 3 (71%). The majority of patients were female (75%); mean age was 45 years (standard deviation: 18). Triage pain score was not documented for 21%. When documented, pain scores were most frequently between 4 and 7 (49%). Nearly 10% of patients left without being seen. For those who were assessed, physicians most frequently used ketorolac and metoclopramide as first or second line treatments or as a combination treatment. Consults were infrequent (14%). Nearly half of the patients (47%). had computed tomography (CT) in the ED. Pain re-assessment was completed for 69% of patients. Most patients were discharged from the ED (88%) and given some form of discharge instruction (78%). The most common instructions were to return to ED as needed (45%) and follow-up with their primary care physician (28%). Across all patients, 13% returned to the ED with headache within 30 days. Conclusion: Physicians treat patients with benign headaches appropriately and hospitalization is infrequent; however, one in eight patients relapse. Missing pain scale documentation reveals a potential problem for ED clinicians in assessing management effectiveness and ensuring patients leave the ED following pain relief. Half of the patients received a CT scan, highlighting the urgent need for an intervention to address CT overuse for patients with benign HA within this geographic region.