Introduction / Innovation Concept: Junior residents are often the first physicians who attend to the acutely unwell floor patient, especially at night and on weekends. The ‘Nightmares Course’ at Queen’s University was designed to address an Entrustable Professional Activity (EPA) relevant to several residency programs at the ‘Foundations of Discipline’ level of training: “to manage the acutely unwell floor patient for the first 5-10 minutes until help arrives”. In keeping with competency based medical education principles, this course offers longitudinal and repetitive practice and assessment. We have also designed a summative objective structured clinical exam (OSCE) in order to identify trainees who require additional remedial practice of this EPA. Methods: We developed simulated cases that reflect common but “scary” calls to the floor. We then, using a modified Delphi process with experts in resuscitation, defined relevant milestones applicable to the Foundations of Discipline level of training in order to inform our formative assessment. We also modified the Queen’s Simulated Assessment Tool (QSAT) to adopt CBME terminology and this will be used to provide a summative assessment during a four-scenario OSCE in the spring. Residents with QSAT scores below the competency threshold will be enrolled in a remediation course. Curriculum, Tool, or Material: Weekly sessions were led by staff physicians and were offered to first-year residents from internal medicine, core surgery, obstetrics and gynecology, and anesthesiology over the academic year. Each resident participated in one session every 4-week block. Sessions were organized into themes such as “shortness of breath” or “decreased level of consciousness” and involved three high-fidelity simulated cases with a structured debrief following each case. Formative feedback was given following each case. Conclusion: The Nightmares Course is a novel simulation-based, multidisciplinary curriculum in resuscitation medicine. It includes longitudinal practice and repetitive assessment, as well as summative testing and remediation of an EPA common to several residency programs.

Introduction / Innovation Concept: Point-of-care ultrasound (POCUS) is becoming standard of care in Canadian emergency departments. However, its integration in Emergency Medicine (EM) residency training is poorly studied. If a four-week curriculum can successfully teach POCUS skills to residents, this program could have potential application across specialties and across Canada. Methods: A four-week curriculum was designed, implemented, and evaluated. EM residents registered for the Introductory Ultrasound Rotation at Sunnybrook Health Sciences Centre were invited to participate. Curriculum evaluation included resident feedback, pre-rotation and post-rotation knowledge and skill testing, and a delayed post-rotation survey. Comparison of pre-test and post-test scores were calculated using the paired t-test. Curriculum, Tool, or Material: Residents were scheduled for both dedicated ultrasound scanning shifts and clinical shifts with an emphasis on POCUS in patient care. Residents also reviewed the Canadian Emergency Ultrasound Society Emergency Department Echo DVD and manual, completed weekly readings and assignments, and completed a “clinical encounter worksheet” describing how POCUS impacted clinical care in a patient encounter. Other rotation activities included Ultrasound Rounds where residents presented a critical appraisal of a POCUS-related journal article, Pediatric Ultrasound Rounds at The Hospital for Sick Children, and an advanced POCUS workshop day. Of 13 eligible residents, 12 (92%) completed at least one study assessment. However, only 8 residents (62%) completed both the pre-test and post-test, 8 residents (62%) completed the end-of-rotation survey, and even fewer residents (42%) completed the delayed post-rotation survey. Residents felt the quality of the ultrasound rotation was excellent (mean score 4.7 on 5-point Likert scale). There was an increase in test scores from a baseline of 51.5% to 70.8% on the post-rotation test (p=0.02). Three months after the rotation, 100% of residents reported feeling either comfortable or extremely comfortable teaching and using the core POCUS topics covered in the curriculum. All residents reported that they would recommend the rotation to their colleagues without hesitation. All residents passed the national ultrasound certification examination at the end of the rotation. Conclusion: A four-week curriculum was effective in teaching EM residents POCUS skills. Further study is required to determine the ideal method for teaching POCUS skills in this group.

Introduction: Pericarditis is a common disease associated with significant morbidity. In adults with pericarditis, we sought to determine if colchicine, in addition to standard therapies, could reduce the incidence of pericarditis recurrence, shorten the duration of symptoms and minimize adverse effects associated with other therapies. Methods: We followed PRISMA guidelines. We performed an electronic search (February 2015) through MEDLINE, EMBASE, CENTRAL, Web of Science, and Google scholar. Online trial registries were searched and reference lists were handed searched. Our search strategy had no limitations on study design, outcome of interest, hypothesis, language, dates or publication status. Inclusion criteria for selected manuscripts were: RCTs; adults; outpatient therapy; and idiopathic/viral/autoimmune pericarditis etiology. Cohen's unweighted kappa for inter-observer agreement was calculated. Data was extracted using a standardized data collection tool. Following assessment of homogeneity between studies, we performed a meta-analysis using (fixed or random) effect models and report odds ratios (OR) with 95% confidence intervals (CI). We assessed bias using GRADE. Results: We screened 647 titles/abstracts, and selected 34 manuscripts for full review (kappa 0.86, CI 0.76-0.96). 7 manuscripts met all inclusion criteria comprising 1,275 patients. We obtained the following OR with 95% CI: 1) For the overall incidence of recurrence of pericarditis (OR 0.32; CI 0.24-0.42); 2) For recurrent pericarditis at 18-months (OR 0.32; CI 0.23-0.44); 3) For event-free of recurrent pericarditis at 18-months follow-up (OR 3.40; CI 2.46-4.70); 4) For persistent symptoms at 72 hours (OR 0.29; CI 0.21-0.41); and 5) For the overall adverse events rate (OR 1.27; Cl 0.84-1.92). Conclusion: Colchicine reduces the number of pericarditis recurrences and the duration of symptoms in patients with recurrent or acute pericarditis. Unless there are contraindications to its use, colchicine should be prescribed in all cases of uncomplicated pericarditis, along with standard therapy.

Introduction: Patients with atrial fibrillation (AF) of <48 hours duration often present to Emergency Departments (ED). Electrical or chemical cardioversion can be employed to restore normal sinus rhythm (NSR). Current guidelines make no recommendations between these two methods and the management decisions are left to the discretion of the treating physician. The objective of this study was to compare these two approaches in terms of ED length of stay (LOS), success (conversion to NSR) and health related outcomes. Methods: At six western Canadian EDs, eligible adult patients were assigned to one of two groups following concealed allocation and using a centralized computer-generated randomization method: electrical cardioversion (EC) first (followed by chemical cardioversion [CC] if the primary method failed) or CC first (followed by EC if the primary method failed). Baseline evaluation/interview and 3/30 day telephone contact were completed and documented using the REDCap data-platform. Adverse events were externally adjudicated in a blinded-fashion. An intention to treat analysis was performed. Results: Overall, 84 patients participated in the study (EC: 43; CC: 41); the median age was 60 years (interquartile range [IQR]: 50, 66), and 38% were female. The baseline patient characteristics in both groups were similar. The median LOS between randomization and conversion to NSR (intervention LOS) was 1.0 hrs (IQR: 0.8, 2.7) in EC vs. 3.1 hrs (IQR: 2.0, 3.9) in CC (p<0.001); more patients in EC were discharged from the ED within 4 hours than in the CC group (65% vs. 32%; p=0.002). The majority of EC patients (84%) converted to NSR after the first attempt while half of the patients did so in the CC group (49%). No differences were observed in terms of adverse events (26% vs. 24%; mostly minimal), hospitalizations (0%), and patients’ health outcomes (physician/ED visits, admissions, stroke) and status (SF-8) at 3 and 30 days, in groups EC and CC groups, respectively. Conclusion: Electrical cardioversion was associated with a statistically significant and clinically meaningful reduction in the LOS when compared to cardioversion using chemical management. Similarities in the proportions of success, adverse events and health outcomes between the groups would support the use of electrical shock as the first approach for cardioversion in clinical practice.

Introduction: Suspicion of arrhythmias among syncope patients is the leading cause of emergency department (ED) referrals and hospitalization. However, the risk factors for short-term arrhythmias are not well defined. We sought to develop a risk prediction tool to identify syncope patients at risk for 30-day arrhythmia or death after ED disposition. Methods: This prospective cohort study involved 6 academic EDs that enrolled adult syncope patients. We collected standardized variables at index presentation from history, clinical examination, investigations including ECG, and patients’ disposition. Adjudicated outcomes included death (due to arrhythmia or unknown cause), arrhythmia or procedural intervention to treat arrhythmias within 30-days after ED disposition. Multivariable logistic regression was used to derive the model; bootstrap sampling for internal validation and to estimate shrinkage and optimism. Results: 5,010 adult syncope patients (mean age 53.4 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (3.6%) patients suffering arrhythmia or death within 30-days after ED disposition. Of 39 candidate predictors examined, eight were included in the final model: vasovagal predisposition, heart disease, any ED systolic blood pressure <90 or >180 mmHg, troponin (>99%ile), QRS duration >130msec, QTc interval >480msec and ED diagnosis of cardiac, or vasovagal syncope [Optimism corrected c-statistic: 0.91 (95%CI 0.87-0.93); Hosmer-Lemeshow p=0.08]. The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% for a score of -2 to 74.5% for a score of 8. Sensitivity for threshold score ≤-1 was 100% (95% CI 96.5-100) and specificity for a score of ≥4 was 97.0% (95% CI 96.5-97.5). Conclusion: The Canadian Syncope Arrhythmia Risk Score can improve acute management of ED patients with syncope by better identification of those at higher-risk for short-term arrhythmia or death. Once validated, the tool can be used to guide disposition decision and can also aid in selection of patients for out-of-hospital cardiac monitoring if discharged home.

Introduction / Innovation Concept: In 2008, the Accreditation Council for Graduate Medical Education endorsed a change such that EM residency programs can decrease their synchronous conference experiences by up to 20% in exchange for asynchronous learning - Individualized Interactive Instruction (III). Identifying quality online resources that would also fulfill III’s reporting criteria (program director monitoring, evaluation component, faculty oversight, program effectiveness) is challenging. Using crowdsourced expertise, the Approved Instructional Resources (AIR) series from Academic Life in Emergency Medicine (ALiEM) was created in 2014 to provide a credible method to identify quality educational blogs and podcasts. The identified resources, however, focused on basic content with limited utility for more senior residents. We thus created the AIR-Pro series in 2015, aimed to cover more advanced concepts. Methods: The AIR-Pro series is a continuously building curriculum covering a new subject area every 2 months. For each area, 6 EM Chief Residents identify 3-5 advanced clinical questions. Using FOAMsearch.net to search blogs and podcasts, relevant posts are scored by 8 reviewers from the AIR-Pro Board (faculty and chief residents at various institutions). The scoring instrument contains 5 measurement outcomes (7-point Likert scale): recency, accuracy, educational utility, evidence based, and references. The AIR-Pro Approved label is given to posts with a score of ≥28 (out of 35) points and these are featured in the blog posting. For scores of 26-27, an Honorable Mention label is given if Board members collectively felt that they were valuable. For each AIR-Pro subject area, a multiple choice quiz is written based on the featured posts. Educator dashboard access of the Google Drive quizzes is given to program directors for monitoring. If approved by their program director, EM residents receive official III credit upon completion of each quiz. Curriculum, Tool, or Material: As of Jan 1, 2016, there have been 2 modules published on ALiEM with 1,220 (Cardiovascular) and 1,059 (Trauma) pageviews worldwide. Although early in development, 21 different institutions are using the AIR-Pro Series with over 150 residents completed the cardiovascular and trauma quizzes. We anticipate more because the original AIR Series has over 73 programs using it for III credit. Conclusion: The AIR-Pro series is a novel, objective, crowdsourced approach towards identifying quality, educational, social media content for the advanced EM resident.

Introduction / Innovation Concept: Trauma resuscitation requires a multidisciplinary team to perform at a high level within a dynamic, high-stakes environment. The unpredictable nature of trauma care increases the possibility for errors, often from underlying latent safety threats (LSTs). In-situ simulation (ISS) is a point-of-care training strategy that occurs within the patient care environment involving the actual healthcare team and provides a novel approach to team training and LST identification. Using ISS, critical events can be recreated providing an opportunity to explore and learn from past challenges. We developed and piloted a risk-informed, multidisciplinary ISS trauma training program to assess teamwork performance and identify LSTs within the trauma care environment. Methods: A comprehensive process was initiated to gain support from all stakeholders within the trauma program. Simulation cases were derived from a review of adverse events and unexpected deaths. Human factors experts aided with the integration of system- and process-related elements into the case design. ISS sessions involved all trauma team members. Debriefing after each session facilitated a team-based discussion and an opportunity for reflective practice and video recording was used for teamwork evaluation and process mapping. Curriculum, Tool, or Material: We conducted monthly, unannounced, multidisciplinary, high-fidelity ISS scenarios at a Canadian Level 1 trauma centre. The trauma team was activated by the usual notification process and care provided in the same manner as an actual trauma patient. A semi-structured debriefing followed each session with a focus on team performance and LST identification. Teamwork was measured using a previously validated tool, the Clinical Teamwork Scale. Findings were used to inform discussion at multidisciplinary trauma rounds as part of an iterative process of evaluation and implementation. Conclusion: This multidisciplinary ISS trauma training program offers a novel approach to team performance evaluation and LST identification. Using risk-informed scenarios combined with human factors analysis we are able identify knowledge and technical skill proficiency gaps, LSTs and integrate formative team assessment. An iterative process beginning with ISS followed by multidisciplinary rounds provides a robust framework for system-based changes to improve team performance and overall patient care.

Introduction / Innovation Concept: The 2015 CanMEDS framework requires all Canadian residency programs to increase their focus on Quality Improvement and Patient Safety (QIPS). A survey of the FRCP Emergency Medicine Residency Program Directors in Canada (63% response rate, 8/13) found that 75% (6/8) of programs have QIPS curricula with 84% (5/6) in the form of didactic lectures and 67% (4/6) as resident participation in a local project. Lectures alone do not expose learners to the practicality of conducting a QIPS project, and local resident projects often do not expose learners to the complexities of organization-wide QI initiatives. Furthermore, QI initiatives require working in interdisciplinary teams. We therefore hypothesize that an effective QIPS curriculum will require multiple education methods delivered using a multi-disciplinary lens. Methods: A collaborative longitudinal QIPS curriculum for emergency medicine residents at the University of Toronto (UT) was developed using multiple educational methods by physicians and non-medical QI specialists. The curriculum addresses three levels of QIPS training: Knowledge (lectures in PGY1 and 2), practical skills at the local clinical microsystem level (QI project in PGY3), and practical skills at the organization level (problem solving using the case method in PGY5). Curriculum, Tool, or Material: The lectures are taught by physicians involved in local and organization-wide QI projects and by those in senior management. The PGY3 residents enrol in a co-learning curriculum developed by the Department of Medicine, where residents and faculty conduct a local QI project together. The PGY5 teaching cases were created with management consultants using material from a real hospital QIPS initiative. PGY5s are taught using the case method that places the learner in the role of the organization’s manager who discusses the issues in class and proposes actions. Residents learn about the practicality of their recommendations by discussion with the management consultants, who disclose the case outcomes and review the lessons learned. Conclusion: A longitudinal QIPS curriculum for emergency medicine residents at UT was developed collaboratively. Multiple teaching methods address all three levels of QIPS training. This curriculum represents a novel use of the case method to instruct QIPS project leadership and management outside of the business school setting. Discussions with management consultants provide a different perspective of the real-life challenges of conducting QIPS initiatives.

Introduction: Patients with low-acuity (CTAS level IV and V) complaints often use the emergency department (ED) to access care. This has often been attributed to lack of a primary care (PC) provider. However, simply being registered with a primary care practitioner may not prevent low acuity ED presentation. There is some evidence that a lack of timely access to primary care may contribute to low acuity ED presentations. The Wait Time Alliance, a group of Canadian physicians and their respective professional associations, has recently set a benchmark of same day access to family doctors. It is unclear if this benchmark has been achieved in all jurisdictions. Methods: We performed linked cross sectional surveys to quantify the number of people presenting to a tertiary hospital ED (with 56,000 annual visits) with non-urgent problems who felt unable to access PC. PC practices were also surveyed to assess access using the metric of time to third next available appointment. Sample size calculations were completed. Descriptive statistics were reported. Results: In the patient survey, 381 of 580 patients consented to participate. Of those, 89 patients met eligibility criteria. 32 (35.9%) reported that the wait to see their PC provider was “too long”. 45 (50.5%) patients did not contact their PC office prior to ED presentation. 46 of 72 PC physician surveys were returned; a response rate of 63.8%. The mean time to third next available appointment in the region was 7.7 (95% CI 4.9-10.5) days (median 5 days, range 0-50 days). Conclusion: Fifty percent of low acuity patients did not attempt to access their PC provider prior to ED presentation. The benchmark of same day access to primary care has not been achieved in many practices in this region. Initiatives to promote primary care access would benefit both patients and providers.

Introduction: Barriers to completing high quality work-based assessments (WBAs) include relational factors such as the episodic and fragmented interaction that often exists between clinical supervisors and trainees. In an effort to increase supervisor-trainee continuity, the Department of Emergency Medicine at the University of Ottawa created Clinical Teaching Teams (CTT) in which a resident and clinical supervisor work matched shifts together throughout the year. The aim of this study was to determine the impact of supervisor-trainee continuity on the quality of assessments documented on Daily Encounter Cards (DECs). Methods: DECs completed by 20 clinical supervisors were collected and sorted into three groups representing differing degrees of supervisor-trainee continuity (Group 1: CTT emergency resident; Group 2: non-CTT emergency resident; Group 3: non-CTT off-service resident). DECs were scored using the Completed Clinical Evaluation Report Rating (CCERR), a 9-item instrument that has been shown to have reliable ratings and the ability to discriminate the quality of completed DECs. Scores were analyzed using a univariate ANOVA with “mean CCERR score” as the dependent variable and “continuity group” and “supervisor” as between-subject variables. The relationship between CCERR scores and number of CTT encounters over time was examined using a repeated measures ANOVA with “encounter number” as the within-subject factor. Results: Mean CCERR scores for the CTT (21.0, SD=5.8), non-CTT (21.9, SD=4.2), and off-service (20.7, SD=4.0) groups differed (p=0.019). A subsequent pairwise comparison demonstrated a statistically significant difference in means between the non-CTT and off-service groups (p=0.04); however, this 1.2 difference on the 45-point CCERR scale is unlikely to be of any educational significance. The number of repeated encounters did not have a statistically significant effect on CCERR scores (p=0.43) indicating that DEC quality did not improve with greater supervisor-trainee interaction. Conclusion: DEC quality as scored by the CCERR was low for all three groups. Increasing supervisor continuity alone did not result in higher quality assessments of clinical performance. Additional research focusing on the educational alliance that develops between supervisor and trainee may hold greater promise.

Introduction: Organizations including CAEP, CEUS, the International Federation for Emergency Medicine (IFEM) and the Canadian Association of Radiologists have all called for defined competency assessments for point of care ultrasound (PoCUS). Definitions of core indications vary. The requirement for ongoing assessment of performance and skills maintenance is often overlooked. We describe the introduction an IFEM approved Assessment of Practice (AP) tool across a PoCUS training program and for continued assessment. Methods: We completed a cross sectional survey and cohort study including the entire body of emergency medicine physicians at a tertiary hospital. Over a 3 year period, all practitioners were assessed for CAEP position statement defined core applications at baseline and again after 2 years using a published PoCUS AP tool. We describe the tool, its application and the performance assessment findings. Emergency physicians (EP) underwent AP following formal training including an approved course and a logbook documenting a variable number of scans. Results: 23 EPs completed training and underwent AP initially, with all 23 EPs completing further assessment within 3 years. Assessment of practice was completed for 1. Focused Diagnostic Ultrasound Assessment for AAA, eFAST, cardiac, early pregnancy; and 2. Focused Procedural Ultrasound Guidance for venous catheterization. All EPs demonstrated initial and continuing competency in these PoCUS modalities. Conclusion: The IFEM PoCUS curriculum promotes ongoing local assessment of performance. We successfully implemented this competency based approach and demonstrated feasibility, flexibility and utility in a Canadian emergency medicine program.

Introduction: Gingivostomatitis is a common, painful pediatric presentation, and yet, few studies are available to guide management. We aimed to describe pediatric emergency physicians’ current practice patterns, with respect to analgesic use in children with acute gingivostomatitis. Methods: A national survey was conducted at all 15 national academic pediatric centres. Electronic surveys were distributed to pediatric emergency physicians using a modified Dillman protocol; non-respondents received paper surveys via post. Data were collected regarding demographics, clinical behaviour, knowledge, perceived barriers and factors that influence practice. Results: Overall response rate was 74% (150/202). Most physicians preferred the combination of acetaminophen and ibuprofen (72%) to either agent alone (ibuprofen 19%, acetaminophen 7%). The preferred second-line analgesics were oral morphine (48%, 72/150) and compounded topical formulas (42%, 64/150). The most commonly cited compounded agent was Benadryl plus Maalox (23%, 35/150). Clinical experience with a medication appeared to be the greatest influence on practice patterns; with 52% (78/149) ‘strongly agreeing’ that this was a factor. The most commonly cited barrier to adequate analgesia was difficulty in administration of topical or oral medication to children. Conclusion: As with many other painful conditions, acetaminophen and ibuprofen are reported to be used most frequently. However, oral morphine and topical compounded agents were also frequently prescribed. Regardless of patient age, physicians preferred oral morphine as a second-line agent to treat pain from severe gingivostomatitis. Future research should focus on determining which analgesic and route (oral or topical) is the most effective and best-tolerated choice.

Introduction: Multiples barriers to appropriate analgesia are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies. Our objective: was to evaluate the improvement in the accessibility of pain and anxiety management strategies in Canadian PEDs, after the creation of a national pediatric pain Quality Improvement Collaborative (QIC), through Pediatric Emergency Research Canada (PERC). Methods: In 2013, the TRAPPED 1 survey was administered to Canadian PEDs, in order to evaluate what resources were in place for pain and anxiety management. A pain QIC was then created to stimulate the implementation of new strategies, through information sharing between PEDs. In 2015, the TRAPPED 2 cross sectional survey was administered. Its focus was to evaluate the improvement in the accessibility of specific strategies reported by each centre, after participating in this QIC, and working to implement change within their own PEDs. Results: All 15/15 Canadian PEDs responded to the TRAPPED 1 survey in 2013 and 11 agreed to participate in the national pain QIC. In-person, phone meetings, follow up surveys and email communications were employed for information sharing. Strategies identified by the QIC to be newly introduced in individual centres were educational initiatives, distraction options, nurse-initiated protocols and intranasal (IN) medications. All 15 PEDs completed the TRAPPED 2 survey. Compared to 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment in 2015. Use of reminder posters on pain management at triage increased from 4/15 to 6/15 PEDs. Availability of tablets for distraction increased from 4/15 to 10/15 PEDs. Nurse-initiated protocols for topical anesthetic and oral sucrose (for needle procedures) increased from 10/15 to 12/15 sites and from 12/15 to 14/15 sites respectively. Availability of IN medications increased; fentanyl from 9/15 to 14/15 sites and midazolam from 8/15 to 10/15 sites. Ten of the 11 PEDs involved in the QIC strategy reported the implementation of at least one of their own identified strategies. Conclusion: This study suggests that the use of a QIC may improve the introduction of new strategies to reduce pain and anxiety in EDs. QICs may also be helpful to other centres when introducing new strategies.

Introduction: Recognition of life-threatening conditions, such as brain tumours, remains a challenge among pediatric patients. Few studies have described the implication of initial presentation, clinical evolution and healthcare system factors in diagnosis delay of brain tumours in children. We aimed to determine the clinical presentation patterns and health care trajectory of children with a diagnosis of primary brain tumour. Methods: A retrospective chart review in a pediatric university-affiliated hospital was conducted. Participants were all patients less than 18 years of age diagnosed with a brain tumour by neuroimaging between Jan 2003 and Dec 2014. Data were extracted from an institutional tumour registry and medical records. Results: From the registry, 288 patients were identified. The mean age at time of diagnosis was 7.44 ± 0.29 years. Most tumours were infra-tentorial (55%) and had astrocytic origin (29%). The majority (35%) had consulted only once prior to diagnosis, while 14% had consulted at least 4 times prior to diagnosis. The mean time between the onset of symptoms and diagnosis was 147 ± 19 days. The mean time between symptoms onset and first consultation was 84 ± 14 days. The most frequent symptoms and signs at onset and diagnosis were respectively: headache (44% vs 59%, p<0.01), nausea and vomiting (31% vs 58%, p<0.01) and abnormalities of gait (10% vs 32%, p<0.01). 129 patients (45%) were diagnosed in an Emergency Department (ED). Symptoms and signs that differed significantly for those diagnosed in an ED were: headache (71% vs 42%, p<0.01), nausea and vomiting (73 % vs 32%, p<0.01), lethargy (26% vs 9%, p<0.01), weight loss (15% vs 3%, p<0.01), irritability (9% vs 0%, p<0.01) and endocrine abnormality (2% vs 8%, p=0.02). Clinical presentations of infants up to one year of age (14%) differed from other age groups. They presented mostly with growth abnormality (46%), macrocephaly (40%), irritability (40%), development abnormalities (18%) and sun-setting eyes sign (10%). Conclusion: In this large comprehensive cohort, we have found that the diagnosis of primary brain tumours is most frequently made in the ED. Different clinical presentations have been identified and varied between different settings of diagnosis and different age groups.

Introduction: L’Unité de coordination clinique des services pré-hospitaliers d’urgence (UCCSPU) est un plateau clinique rattaché au CSSS Alphonse-Desjardins (CHAU Hôtel-Dieu de Lévis) qui permet un soutien médical à distance des patients transportés par ambulance dans la région de Chaudières-Appalaches (CA). En 2011, un projet novateur, devenu programme par la suite, a été instauré afin de réaliser des constats de décès à distance (CDD). Le but du programme est de réduire le nombre de transport de patients décédés vers les hôpitaux afin de remettre rapidement en service l’équipe ambulancière. Le but de l'étude est de décrire et comparer le taux de CDD et le gain de temps sur la remise en service de l’équipe ambulancière avant et après l’implantation du programme de CDD dans deux différentes régions géographiques (Chaudières-Appalaches et Saguenay-Lac-St-Jean (SLSJ)). Par la suite, déterminer s’il existe une distance minimale à partir de laquelle ce gain de temps est nul pour chaque région. Methods: Il s’agit d’une étude rétrospective portant sur 204 personnes réparties en 4 groupes : 2 groupes témoins [CA pré-CDD (50) et SLSJ pré-CDD (50)] et 2 groupes d’étude [CA post-CDD (52) et SLSJ post-CDD (52)] pour les deux régions. Le pourcentage de CDD réussi (taux de réalisation) par région et les gains de temps entre chaque groupe (intra- et inter-région) en fonction de la distance avec le centre hospitalier (CH) ont été calculés. Results: Pour un même nombre de patients, le taux de réalisation de CDD est similaire entre les deux régions [CA=80% (6 mois) et SLSJ=76% (4 mois)]. Le temps de remise en service des ambulances est différent (p<0.05) inter-région se caractérisant par des gains de temps moyens de 62 min (CA) et 28 min (SLSJ). Enfin, la distance minimale où le gain de temps est nul est de moins de 5 km pour chaque région. Conclusion: L’implantation du programme de CDD permet un gain de temps favorisant un retour plus rapide des services pré-hospitalier d’urgence si la distance entre le lieu du CDD et du CH est supérieure à 5 km. De plus, le gain en temps est proportionnel avec la distance entre le lieu du CCD et le CH.

Introduction: The percentage of unplanned return visits (URV) to the Emergency Department (ED) within 48 or 72 hours of discharge that result in an admission to hospital has been recommended as the top Canadian ED patient safety quality indicator. International data exists although inconsistences exist in the way URV are defined and measured. To our knowledge there are no published Canadian data on the percentage of ED URV admissions. This study examines our own URV data and in particular the correlation between URV admission rates and first visit Canadian Triage Acuity Scale (CTAS) category. Methods: A retrospective analysis of 12-month’s data (January - December 2015) was completed for URV to the ED of a 445 bed regional tertiary care adult and pediatric teaching hospital with 57,000 annual attendances. URV was defined as any patient registering within 72 hours of an earlier visit that had resulted in a discharge from ED. Planned return visits were excluded. The data was analysed for an overall URV percentage, UV percentage by first visit CTAS category, overall percentage of URV admitted and URV admission percentage by first visit CTAS category. Pearson R correlation and Fishers Exact Test were used to test the relationship. Results: During the 12-month period there were 57,025 registrations of which 46,793 patients were discharged. There were 3566 URV (7.62% of those discharged); the number of URV admitted was 532 (1.14 % of those discharged). The return rate/admission rates by CTAS category were: CTAS 1: 6.74%/1.55%; CTAS 2: 7.86%/1.92%; CTAS 3: 8.54%/1.35%; CTAS 4: 5.99%/0.40%; CTAS 5: 5.55%/0.27%. The RR of admission on return for discharged CTAS groups 1 and 2, compared with CTAS 3, 4 and 5 was 1.90 (95 CI 1.57 to 2.30; p<0.0001). Rate of admission on return was negatively correlated with initial CTAS level (Pearson r = -0.89 (95 CI -0.99 to -0.03); R2=0.79; F=11.25; p=0.04). Conclusion: We have demonstrated a relationship between first visit CTAS category and the unplanned return admission rate. If admission is taken as a marker of illness severity, then the likelihood of an inappropriate discharge is inversely proportional to first visit CTAS score. While this makes sense intuitively, our data confirms this relationship in a Canadian tertiary care hospital and supports the reporting of ED URV admission data by first visit triage category as an important quality indicator.

Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive, continuous and painless method of monitoring oxygen saturation of hemoglobin in any given superficial tissue. Given that hemodynamic instability can affect the oxygen saturation, NIRS could prove to be an interesting tool in quantifying tissue oxygenation, consequently guiding clinical management. The aim of this study was to compare the reliability of two commonly used tissue oximeters, the INVOS 5100c from Covidien and the Equanox 7600 from Nonin. We postulated the Equanox (a more recent tissue oximeter) would have a better reliability than the INVOS. As a secondary outcome, we evaluated whether the measures given by the two oximeters were comparable. Methods: The study population was composed of healthy adult volunteers. Three measurements were taken at six different sites on both sides of the body in a randomized order. Two different sensors were used for each measure. From these measures, two intra-class correlations (ICC) - one inter-sensor and the other intra-sensor - were calculated for each device and compared using the Fisher’s r-to-z transformation method. An additional inter-device ICC was also calculated. We considered ICCs over 0.75 as an indicator of good reliability, while ICCs under 0.40 were considered to represent poor reliability. The sample size was calculated based on the calculation of a unidirectional confidence interval for a parametric ICC. Expecting a 0.75 ICC value, we concluded that 53 participants needed to be recruited in order to attain 80% power and a range of 0.1 towards the low values. Results: Fifty-three healthy volunteers (27 men and 26 women) with a mean age of 31 years (standard deviation 10) were recruited. We found no differences between the repeatability of the INVOS and the Equanox for both inter and intra-sensor reliability (ICC=0.94 (95% confidence interval (CI) 0.86-0.97) versus ICC=0.92 (95%CI 0.86-0.95), p=0.42 and ICC=0.94 (95%CI 0.89-0.96) versus ICC=0.96 (95%CI 0.93-0.98), p=0.21, respectively). However, when compared directly, we found that the readings produced by the two oximeters varied considerably (ICC 0.18 (95%CI -0.10 to 0.43). Conclusion: When taken individually, both tissue oximeters displayed good inter and intra-sensor reliability. However, they oximeters displayed poor inter-devices agreement, their readings varying considerably amongst each other.

Introduction: Youth injured by violence is a major public health concern in Canada. It is the fourth leading cause of death in youth and the foremost reason youth visit an emergency department (ED). In Winnipeg, 20% of youth who visit an ED with an injury due to violence will have an ED visit for a subsequent violent injury within one year. Youth injured by violence are in a reflective and receptive state of mind, rendering the ED setting appropriate for intervention. Methods: We completed a randomized control trial in November 2015 comparing wraparound care for youth age 14 - 24 who were injured by violence to standard ED care. Youth were excluded if their injury was due to child maltreatment, sexual assault or self-harm. An adapted pre-consent randomization methodology was used. The intervention was developed using a community based participatory research approach. Wraparound care was delivered by a support worker with lived experience with violence. Support workers were on call 24/7 in order to start the intervention in the ED and take advantage of the “teachable moment.” Care continued in the community for approximately one year. Results: A total of 133 youth were randomized (68 intervention, 65 control) in one year. There was no difference in age, gender, or severity of injury between the two groups. Patients randomized to the intervention spent a median of 30 minutes less in the ED than those receiving standard care (p=0.22). Youth are safely housed, have enrolled in education opportunities, and are engaged in addictions care. Results of a chart review examining repeat visits to the ED for violent injury, substance use and mental health will be completed in Spring 2016 and will be presented. Conclusion: There were no differences between standard care and intervention groups on baseline characteristics reflecting effective randomization. The introduction of an intervention at bedside in the ED did not have a negative impact on patient length of stay.

Introduction: The addition of computerized physician order entry (CPOE) to Emergency Departments in recent years has led to speculation over potential benefits and pitfalls. Recent studies have shown benefits to CPOE, though there lacks sufficient evidence on how it could change physician behaviour. Physician practices are known to be difficult to change, with getting evidence into daily practice being the main challenge of knowledge translation. Our study aims were to determine if well-designed electronic order sets for CPOE improved MD practices. Methods: The Calgary Zone Pain Management in the Emergency Department Working Group relied on a GRADE-based literature review for identifying best practices for analgesia and antiemetics, resulting in soft changes to the dedicated analgesia and antiemetic electronic order set noting working group preference, and emphasizing hydromorphone over morphine, as well as 4 mg ondansetron over 8 mg. The new electronic order set was started in the only Calgary Region order entry system on December 11th, 2014. Data was collected from July 2014 - May 2015. A Yates chi-squared analysis was completed on all orders in a category, as well as the subgroups of ED staff and residents, and orders placed using the new order set. Results: A total of 100460 orders were analyzed. The use of hydromorphone increased significantly across all 4 EDs. IV hydromorphone use increased (5.82% of all opioid orders up to 26.93%, P<0.0001) with a reciprocal decline in IV morphine (67.81% of all opioid orders down to 46.56%, P<0.0001). Similar effects were observed with ondansetron 4 mg IV orders increasing (1.37% of all ondansetron orders to 18.64%, P<0.0001) with a decrease in 8 mg dosing (15.75% of all ondansetron orders to 7.23%, P<0.0001). These results were replicated to a lesser degree in the non-ED staff and non-order set subgroups. Implementation of the new order set resulted in an increase of its use (37.64% of all opioid orders up to 49.29%, P<0.0001). Finally, a cost-savings analysis was completed showing a projected annual savings of $185,676.52 on medications alone. Conclusion: This data supports the manipulation of electronic order sets to help shape physician behaviour towards best practices. This provides another strong argument towards the benefits of CPOE, and can help maintain best practices in Emergency Medicine.

Introduction: The use of cardiac point of care ultrasound (PoCUS) to assess cardiac arrest patients is widespread, although not mandated by advanced cardiac life support (ACLS) guidelines. This study aims to examine if the use of ultrasound, along with the findings on ultrasound are associated with a difference in outcomes of cardiac arrest patients in the emergency department (ED). Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in asystole or PEA cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19, or with a previous DNR order. Patients were grouped based on whether PoCUS was used during ACLS (PoCUS group) and those without PoCUS (control group). Multiple data were abstracted from charts using a standardized form. Data was analyzed for the return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD), as well as initial cardiac activity findings on PoCUS. Results: 230 patients met the study inclusion criteria, with 44 (19%) in the control group, and 186 (81%) in the PoCUS group. In the PoCUS group 20 (11%) had cardiac activity (Positive PoCUS) and 166 (89%) had no cardiac activity recorded. The control group had a higher rate of SHA than the PoCUS group (27%; 95% CI 15-43% vs. 10%: 6-15%, p = 0.0046), however there was no difference in frequency of ROSC (control: 37%; 24-55% vs. PoCUS 26%; 20-33%, p = 0.1373) or SHD (control: 7%, 95% CI 1-19%; PoCUS: 2%, 95% CI 0-5%, p = 0.0858). Positive PoCUS patients had a higher frequency of ROSC (75%; 50-91% vs. 20%; 15-27%, p < 0.001) and SHA (25%; 9-49% vs. 8%; 4-13%, p = 0.0294) than patients with no PoCUS cardiac activity, however there was no difference in the rate of SHD between the positive PoCUS patients (0%; 0-17%) and patients with no PoCUS cardiac activity (2%; 0-5%, p = 1.0000). Conclusion: Our results suggest that there is no difference in survival between cardiac arrest patients receiving PoCUS and those who do not. Although finding positive cardiac activity on PoCUS is associated with greater ROSC and survival to hospital admission, it does not identify patients with a final outcome of survival to hospital discharge.