Introduction: Rural emergency departments (EDs) are important safety nets for 20% of Canadian citizens. In Quebec, the province’s 26 rural EDs treat an average of 19,000 patients/year and are on average 300 km from levels 1 and 2 trauma centers. These distances signify that Emergency Medical Services (EMS) play a considerable role in the care of rural patients. EMS in Quebec province are private local services. There are no published reports on EMS in rural Quebec. As part of a larger study on rural emergency care, this descriptive study aimed at offering a comprehensive portrait of EMS. Methods: We conducted semi-structured interviews with managers of all paramedic services in rural Quebec. Interview questions focused on number of transports, training, availability of telemetry, GPS technologies, and work schedules. Results: Fifty managers of the 51 private companies serving the 26 rural EDs in Quebec were interviewed (response rate 98%). All were primary care paramedics (PCP). In 2010, EMS transported 40,671 patients, with 10,228 emergency transports to the rural EDs. A total of 7956 inter-facility transfers were conducted, 1499 of them emergency. Each ED required between 88 and 700 inter-facility transfers. A total of 60% (n=31/51) had GPS technology, only 25% (n=13/51) had telemetry features. Work schedules varied with 13% (n=7/51) of companies offering shifts of less than 12 hours, 28% (n=14/51) 24/7 weekly shifts, and 56% (n=29/51) a combination. Conclusion: This is the first study to describe rural EMS in Quebec. The finding that Quebec’s rural EDs are served by 51 privately-owned companies is unique in Canada. The considerable number of EMS transports, including inter-facility transfers, may reflect lack of local resources in rural EDs, the vulnerable population served, or the increased trauma risk in rural areas. Future studies should examine inter-facility transport reasons, costs, times and adequate training/scope of EMS practice.

Introduction: The timely diagnosis and treatment of testicular torsion is essential as a longer duration of symptoms is correlated with testicular necrosis and infertility. Ultrasound imaging assists in separating this diagnosis from other causes of acute scrotal pain. Our objective was to characterize which ultrasound findings predicted surgical intervention. Methods: We performed a retrospective health records review of all patients, ages 0-17 years that presented to the emergency department of the Children’s Hospital of Eastern Ontario over a 5-year period (2009-14) with scrotal pain <24 hours duration who were assessed by an emergency physician (EP) and received a testicular ultrasound by the Diagnostic Imaging Department. Patients’ records and ultrasound reports were reviewed by two reviewers who recorded ultrasound findings, times of EP assessment, ultrasound and surgical intervention in a standardized data extraction form. Sensitivity, specificity and positive and negative predictive values were calculated for the ultrasound findings. Results: 190 patients were analyzed of which 34 had a final diagnosis of testicular torsion (mean age 11.5 years, range 0-17.3). The mean time from EP assessment to ultrasound was 67.6 minutes (95%CI 50.5-84.6) during the daytime (800-2159) and 83.2 minutes (95%CI 36.7-130.4) for overnight presentations (2200-759). The absence of blood flow on colour Doppler ultrasound of the affected testicle was the best predictor of surgical intervention (sensitivity=94.1% [95%CI 80.3%-99.3%], specificity=99.4% [95%CI 96.5%-99.9%], positive likelihood ratio=146.8 [95%CI 20.7-1037.7] and negative likelihood ratio=0.06 [95%CI 0.02-0.23]. Other ultrasound findings that help rule in testicular torsion were the presence of a heterogeneous testicle on the symptomatic side (specificity=91.0% [95%CI 85.4%-95.0%] and the presence of the whirlpool sign (specificity=99.4% [95%CI 96.5%-99.9%]). Conclusion: The absence of blood flow on ultrasound is the best ultrasound finding for predicting surgical management of testicular torsion. Neither a heterogeneous testicle nor whirlpool sign had strong enough sensitivity to warrant their independent use. Future studies, such as those utilizing point of care ultrasound by EPs, should be conducted to study the affect on delays in treatment.

Introduction: In response to concerns in the literature over the quality of completed work-based assessments (WBAs), faculty development and rater training initiatives have been developed. The Completed Clinical Evaluation Report Rating (CCERR) was designed to evaluate these interventions by providing a measure of the quality of documented assessments on In-Training Evaluation Reports (ITERs). Daily Encounter Cards (DECs) are a common form of WBA used in the Emergency Department setting. A tool to evaluate initiatives aimed at improving the quality of completion of this widely used WBA is also needed. The purpose of this study was to provide validity evidence to support using the CCERR to assess the quality of DEC completion. Methods: This study was conducted in the Department of Emergency Medicine at the University of Ottawa. Six experts in resident assessment grouped 60 DECs into three quality categories (high, average, poor) based on their perception of how informative each DEC was for reporting judgments of the resident’s performance. Eight clinical supervisors (blinded to the expert groupings) scored the 10 most representative DECs in each group using the CCERR. Mean scores were compared using a univariate ANOVA to determine if the CCERR was able to discriminate DEC quality. Reliability for the CCERR scores was determined using a generalizability analysis. Results: Mean CCERR scores for the high (37.3, SD=1.2), average (24.2, SD=3.3), and poor (14.4, SD=1.4) quality groups differed (p<0.001). A pairwise comparison demonstrated that differences between all three quality groups were statistically significant (p<0.001), indicating that the CCERR was able to discriminate DEC quality as judged by experts. A generalizability study demonstrated the majority of score variation was due to differences in DECs. The reliability with a single rater was 0.95. Conclusion: There is strong validity evidence to support the use of the CCERR to evaluate DEC quality. It can be used to provide feedback to supervisors for improving assessment reporting, and offers a quantitative measure of change in assessor behavior when utilized as a program evaluation instrument for determining the quality of completed DECs.

Introduction: The CETI team has shown that around 18% of otherwise independent seniors remain in a state functional decline up to six months after a minor injury. In that context, frailty may be associated with increased likelihood of decline. As most seniors consult Emergency Departments (EDs) when injured, measuring frailty may help identify those at risk of functional decline. Objectives: This study aims to 1) describe frailty in the sub-group of independent community-dwelling seniors consulting Emergency Departments (ED) for minor injuries, 2) examine the association between frailty and functional decline three months post-injury, 3) ascertain the predictive accuracy of frailty measures and Emergency Physicians’ (EPs) for functional decline. Methods: Prospective cohort in 2011-2013 among 1072 seniors aged ≥ 65, independent in basic daily activities, evaluated in Canadian EDs for minor injuries and discharged home. Frailty was assessed at EDs using the Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) and the Study of Osteoporotic Fracture index (SOF). Functional decline was defined as a loss ≥ 2/28 on the Older American Resources Services scale three months post-injury. Generalized mixed models were used to explore differences in functional decline across frailty levels. Areas Under the Receiver operating characteristic curve (AUC) were used to ascertain the predictive accuracy of frailty measures and EPs’ clinical judgement. Results: The SOF and CSHA-CFS were available in 342 and 1058 participants, respectively. The SOF identified 55.6%, 32.7%, 11.7% patients as robust, prefrail and frail. These CSHA-CFS (n=1058) proportions were 51.9%, 38.3% and 9.9%. The 3-month incidence of functional decline was 12.1% (10.0%-14.6%). The AUCs of the CSHA-CFS and the EPs’ were similar (0.548 - 0.777), while the SOF was somewhat higher (0.704 - 0.859). Conclusion: Measuring frailty in community-dwelling seniors with minor injuries in EDs may enhance current risk screening for functional decline. However, before implementation in usual care, feasibility issues such as inter-rater reliability and acceptability of frailty tools in the EDs have to be addressed.

Introduction: Vancouver Coastal Health (VCH) emergency physicians have been on contract based funding models for two decades. On October 1, 2015, physicians at one hospital (SPH) switched to fee-for-service (FFS) payments. Conventional wisdom is that FFS physicians are motivated to see more patients quickly and achieve higher throughput. Our hypothesis was that FFS payment would reduce patient wait times. Methods: This interrupted time series analysis with concurrent control was performed in VCH Region, where there are two tertiary EDs. During the 20-week study period (July 15-Nov 30), VGH remained on contract, while SPH converted to FFS (the intervention). VCH administrative data was aggregated by week. Our primary outcome was median wait time to MD. Secondary outcomes were ED LOS and left-without-being-seen (LWBS) rates. Results: Interrupted time series plots will be presented for the data. Data from 67,214 ED visits were analyzed (31,733 SPH, 35,481 VGH). Figure 1 shows that baseline wait time was 74 minutes at the control and 53 minutes at the intervention site. During the pre-intervention period, there was a non-significant downward trend of 0.4 minutes per week at the intervention hospital relative to control (p=0.26). After FFS conversion, there was a 4.1 minute increase in wait time at the control site (p=0.18), and a significant downward trend of 1.4 minutes per week (p=0.001). After FFS conversion, wait times at the intervention site increased by 4.8 minutes more than control (p-value for the difference=0.27), and the wait time trend increased significantly by 1.3 minutes per week relative to the expected counterfactual trend (p=0.02). Baseline EDLOS for discharged patients was 227 minutes at the control hospital and 193 minutes at the intervention site. There were similar pre-intervention LOS increases at both hospitals. Post-intervention, both sites saw significant increases in EDLOS, followed by a similar downward trends of -2.68 minutes per week (p=0.001). Baseline LWBS rate was 3.86% at the control hospital and 3.56% at the intervention site. Pre-intervention trends, and post-intervention level/trend changes did not differ by site. Conclusion: Conversion to FFS payment was associated with an increase in wait time trend of 1.3 minutes per week relative to control. There were no significant changes in EDLOS or LWBS rates. In this preliminary analysis, FFS payment had little effect on wait times or patient throughput.

Introduction: Health promotion and disease prevention have been increasingly recognized as activities within the scope of emergency medicine. Exercise prescription by physicians has been shown to improve outcomes in obesity, cardiovascular disease, and many other diseases. An estimated 600,000 Canadians receive the majority of their care from emergency departments (ED), representing a substantial opportunity for health promotion. Our study examined the frequency of exercise prescription by emergency physicians (EPs) and determined factors that influence decisions to prescribe exercise. Methods: A national, confidential 22-item survey was distributed to Canadian EPs via email by the CAEP survey distribution protocol in November/December 2015. Demographics, exercise prescription rates and self-reported exercise habits were collected. Results: A total of 332 EPs responded. 92.4% of EPs reported being at least moderately active. 62.7% of EPs often or always council their patients about preventative medicine (smoking cessation, drug and alcohol use, diet and safe sex). However, only 23.8% often or always ask about their exercise habits. Even fewer (12.7%) often or always prescribe exercise. Training background significantly predicted level of comfort prescribing exercise. CCFP trained EPs were 5.1 (p = 0.001) times more likely than trained EPs to respond 'yes' they feel comfortable prescribing exercise, and 3.7 (p = .009) times more likely to respond 'sometimes'. CCFP (EM) trained EPs were 3.5 (p < 0.001) times more likely than trained EPs to respond 'yes' they feel comfortable prescribing exercise, and 2.0 (p = .031) times more likely to respond 'sometimes'. 76.1% of respondents believe that other EPs rarely or never prescribe exercise. Of respondents, only 36% feel comfortable prescribing exercise. The majority of EPs (73.4%) believe that the ED environment did not allow adequate time for exercise prescription. Conclusion: The majority of EPs council their patients regarding other forms of preventative medicine but few prescribe exercise to their patients. Available time in the ED was cited as a significant barrier to exercise prescription. CCFP trained EPs are more comfortable prescribing exercise, suggesting that their training may better educate and prepare them to council patients on exercise compared to trained EPs. Further education may be required to standardize an approach to prescribing exercise in the ED.

Introduction: Lateral epicondylitis (LE), also known as tennis elbow, is an overuse-underuse tendinopathy originating from the forearm extensor tendons of the elbow. An emerging therapy for the treatment of LE is the use of transdermal nitroglycerin (NTG) patches for pain relief and improved function. Our systematic review assesses 18 to 65 year old patients with clinically diagnosed LE and no structural damage or longstanding elbow injury to determine if transdermal NTG patches provide improved short term and long term pain relief as well as improved function in comparison with placebo. Methods: We included randomised controlled trials (RCT’s) of NTG patch use versus placebo for the treatment of LE. Prospective comparison studies were also eligible for assessing the long term pain relief of NTG patch use. We performed a literature search using MEDLINE, EMBASE, SportDiscus and the Cochrane Database of Systematic Reviews. English language articles were retrieved for review up to November 2015. Risk of bias within the studies was assessed regarding randomisation, allocation sequence concealment, blinding and selective outcome reporting. Results: Three RCT’s were included that compared transdermal NTG patch use (two studies with 1.25mg/24h and one study comparing 0.72, 1.44 and 3.6mg/24h) versus a placebo to treat LE. One prospective comparison study of five years duration was included as a follow-up to one of the included RCT’s to assess pain and function five years after the discontinuation of therapy. Data was not pooled because of heterogeneity in study methods and outcomes. The use of transdermal NTG patches provided short term pain relief (2-6 weeks for dosing of 0.72mg/24h or 1.25mg/24h) compared with placebo as suggested by three RCT’s. Long term pain relief was improved by NTG patch use compared with placebo at six months in one RCT, but not at five years in a prospective comparison study. Function improved in two different RCT’s with NTG patch use at 0.72mg/24h and 1.25mg/24h when compared to placebo. Five years after cessation of treatment, there was no difference between NTG patch and placebo. Conclusion: Overall, the included studies demonstrate that the use of NTG patches compared to placebo improves short term and long term pain relief, as well as elbow function. However, more studies are required to bridge the gaps between the existing studies and reduce heterogeneity between the study designs.

Introduction: Traditional post-conference speaker evaluations are inconsistently completed; meanwhile, real time social media tools such as Twitter are increasingly used in conferences. We sought to determine whether a correlation exists between traditional conference evaluation for a speaker and the number of real-time tweets it generated using data from a CAEP conference. Methods: This study utilized a retrospective design. The hashtag #CAEP14 was prospectively registered with Symplur, an online Twitter management tool, so that all tweets related to CAEP conference 2014 were stored. A tweet was associated with a session if it mentioned the speaker name, or if the tweet content and timing closely matched that of the session in the schedule. A tweet classification system was developed to differentiate original tweets from retweets, and quotes from comments generating further discussion. Two authors assessed and coded the first 200 tweets together to ensure a uniform approach to coding, and then independently coded the remaining tweets. Discrepancies were resolved by consensus. One author reviewed post-conference speaker evaluation, and abstracted the value corresponding to the question “The speaker was an effective communicator”. We present descriptive statistics and correlation analyses. Results: A total of 3,804 tweets were collected, with 2,218 (58.3%) associated with a session. Forty-eight (48%) (131 out of 274) of sessions receiving at least one tweet, with a mean of 11.7 tweets per session (95% CI of 0 to 57.5). In comparison, only 31% (85 out of 274) of sessions received a formal post conference speaker evaluation (p<0.005). For sessions that received at least one traditional post-conference evaluation, there was no significant correlation between the number of tweets and evaluation scores (R=0.087). This can be attributed to the fact that there was minimal variation between evaluation scores (median = 3.6 out of 5, IQR of 3.4 to 3.7). Conclusion: There was no correlation between the number of real-time tweets and traditional post-conference speaker evaluation. However, many sessions which received no formal speaker evaluation generated tweets, and the number of tweets was highly variable between sessions. Thus, Twitter metrics might be useful for conference organizers to supplement formal speaker evaluations.

Introduction: Delays in definitive management of difficult airways in the Emergency Department (ED), often involving coordination with expert consultation from Anesthesia and/or Otolaryngology, can lead to devastating outcomes. Currently at our ED there is no standardized approach to identifying and/or managing predicted difficult airway scenarios. We sought to determine the most common factors contributing to predicted difficult airways in the ED, and areas of time delays in securing a definitive airway. Methods: We conducted a retrospective analysis at a tertiary academic centre (>160,000 ED visits/yr) over a 5 year period. A research assistant screened all cases of “Stat” pages from the ED to the Anesthesia service. An ED clinician performed a thorough review of the charts to confirm difficult airway cases. A single reviewer extracted data on patient demographics, factors associated with a difficult airway, and specific time intervals throughout a patient’s clinical course. We present descriptive statistics with 95%CI. Results: 45 cases met our inclusion criteria between Jan 2010-Dec 2014. 16 were excluded and a total of 29 cases of difficulty airways in the ED were included in our final analysis. The average age was 56.7 (95% CI 50.1-63.4) years, and 68.9% were male. The most common factors contributing to difficult airway included: Obesity (48.2%), previous history of head/neck malignancy/radiation (27.6%), and facial edema (20.7%). 25 (86.2%) required expert assistance from Anesthesia/Otolaryngology for definitive airway, and 8 (27.6%) survived to hospital discharge. The mean time between decision to intubate and “Stat” anesthesia page was 14.0 (95% CI 8.7-19.3) mins. The mean time from “Stat” anesthesia page to arrival of anesthesia MD was 8.4 (95% CI 6.0-10.7) mins. The mean time between arrival of anesthesia MD and definitive airway was 12.1 (95% CI 7.4-16.8) mins. The mean time between decision to intubate and definitive airway was 35.5 (95% CI 27.9-43.1) mins. Conclusion: We found a number of common factors contributing to a patient’s risk of having a predicted difficult airway in the ED, as well as areas of significant time delays in the unstandardized, multidisciplinary management of these cases. Future work is needed on developing, implementing, and evaluating more standardized difficult airway response protocols in the ED.

Introduction: Despite strong evidence that antithrombotic drugs in atrial fibrillation/flutter (AF) patients reduce stroke risk, previous emergency department (ED) pre-novel anticoagulant (NOAC) studies have shown that most discharged patients are not optimally treated. This study sought to determine baseline antithrombotic management in AF patients, and appropriate antithrombotic prescription upon ED discharge since the introduction of NOACs. Methods: Consecutive AF patients discharged by the ED physician from three academic EDs in Toronto, Canada were retrospectively identified using ECG data. Primary AF was defined as AF in patients ≥18 years without congenital heart disease or other acute medical conditions. All management and disposition decisions were left to the discretion of the emergency doctor. Results: From July 2012 to October 2014, 691 patients with primary AF were identified. Of these, 34.4% (n=238) had new onset AF and 66.4% (n=459) were discharged home directly from the ED. Of those with previously known AF (n= 453), 44.2% (n=200) were on anticoagulation at ED arrival (warfarin 59.5%, dabigatran 23.0%, rivaroxaban 11.5%); 25.6% (n=116) on antiplatelets, and 29 (6.4%) on both. Based on 2012 Canadian AF guidelines, 60.1% of those who should have received anticoagulation were receiving it. In discharged patients meeting de novo criteria for anticoagulation (n=130), 20.0% (n=26) were started on anticoagulation and 23.1% (n=30) on antiplatelets. In patients with CHADS2 score ≥ 2 (n=61), 26.2% (n=16) were started on anticoagulation. Warfarin (73.1%) was most commonly prescribed followed by dabigatran (15.4%) and rivaroxaban (11.5%). Age was the only inverse independent predictor for appropriate anticoagulation (OR 0.92 per 5 year of age 95% CI 0.89-0.95, p <0.0001) i.e. older patients were less likely to be anticoagulated. The CHADS2 score was not an independent predictor of appropriate anticoagulation. Conclusion: Our study shows a persistent gap in the antithrombotic treatment of ED AF patients irrespective of their risk.

Introduction: Syncope can be caused by serious life-threatening conditions not obvious during the initial ED assessment leading to wide variations in management. We aimed to identify the reasons for consultations and hospitalizations, outcomes, and the potential cost savings if an outpatient cardiac monitoring strategy were developed. Methods: We conducted a prospective cohort study of adult syncope patients at 5 academic EDs over 41 months. We collected baseline characteristics, reasons for consultation and hospitalization, hospital length of stay and average total inpatient cost. Adjudicated 30-day serious adverse events (SAEs) included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage and procedural intervention. We used descriptive statistics with 95% CI. Results: Of the 4,064 patients enrolled (mean age 53.1 years, 55.9% female), 3,255 (80.1%) were discharged from the ED, 209 (5.2%) had a SAE identified in the ED, 600 (14.8%) with no SAE were referred for consultation in the ED and 299 (7.4%) were hospitalized: 55.5% of referrals and 55.2% of hospitalizations were for suspected cardiac syncope (46.5% admitted for cardiac monitoring of whom 71.2% had no cause identified). SAE among groups were 9.7% in total; 2.5% discharged by ED physician; 3.4% discharged by consultant from ED; 21.7% as inpatient and 4.8% following discharge from hospital. The mean hospital length of stay for cardiac syncope was 6.7 (95%CI 5.8, 7.7) days with total estimated costs of $7,925 per patient (95% CI: 7434, 8417). Conclusion: Suspected cardiac syncope, particularly arrhythmia, was the major reason for ED referral and hospitalization. The majority of patients hospitalized for cardiac monitoring had no identified cause. An important number of patients suffered SAE, particularly arrhythmias outside the hospital. These findings highlight the need to develop a robust syncope prediction tool and a remote cardiac monitoring strategy to improve patient safety while saving substantial health care resources.

Introduction: Regional anesthesia has been shown to be an effective pain control strategy for patients presenting with hip fractures in the emergency department. There are two common methods for performing this block: the femoral nerve block (FNB) and the fascia iliaca compartment block (FICB). The objective of this pilot study is to determine whether one of these two ultrasound-guided block techniques provides superior analgesia to emergency department patients with hip fractures. Methods: Emergency physicians at a single institution were randomized to the FNB or FICB training groups. Participants completed a 2-hour practical workshop covering the technique, followed by a questionnaire to assess their comfort with the block. They were asked to perform their assigned nerve block on any patient in the ED presenting with a hip or femur fracture. Physician comfort level and patient pain scores using a visual analog scale (VAS) were recorded before and after the nerve block were recorded. Comparisons were performed using Student’s t-test and Fisher’s exact test. Results: A total of 20 physicians were enrolled in the study, 10 in the FNB group and 10 in the FICB group. There were no significant baseline differences between the groups with respect to ultrasound or nerve block experience. Following the training, 100% of participants in both the FNB group and FICB group felt comfortable performing the block. Nerve blocks were performed in 30/51 (58.8%) of eligible patients in the FNB group and 6/11 (54.5%) in the FICB group (p=1.0). On the 10-point VAS, pain scores decreased by a mean of 4.9 (SD 3.5) in the FNB group and 8.3 (SD 2.4) in the FICB group (p=0.056). In practice, physicians felt comfortable performing the FNB in 52.8% of cases, and the FICB in 85.7% of cases (p=0.21). Mean time to completion of the blocks was similar between the two groups (19 vs 18 mins, p=0.83). Conclusion: In this pilot study, we found a non-significant trend towards improved analgesia and higher physician comfort with the ultrasound-guided FICB compared with the FNB in patients with hip fractures. We found no differences in time to performing the blocks. These results require confirmation with a larger sample size.

Introduction: The decision to treat with parenteral therapy may reflect a variable practice pattern among emergency physicians and represent an opportunity to standardize care. Our objective was to describe physician level practice variation for IV therapies in patients with low-acuity presentations and quantify the contribution of IV therapy to prolonging ED LOS. Methods: Using administrative data merged with computerized physician order entry information we sampled 48 months of patient variables across four urban EDs (Jan 1, 2014 - Dec 22, 2015). Eligible patients: 1. presented with complaints of abdominal pain, nausea and vomiting or diarrhea or had a discharge diagnosis of cellulitis 2.were in a low acuity category (Canadian Triage and Acuity Scale - CTAS 3 or 4) 3.were triaged to non-stretcher zones of the ED and 4.were not admitted to hospital. The primary outcome was the physician-level variation in the decision to order IV therapies for this patient group; namely one or more of the following: IV fluids, opioid analgesia, anti-emetics and antibiotics. Secondary outcomes were a comparison of ED LOS, ED revisits at 7 days and ED revisits resulting in admission at 7 days for the IV and non-IV groups. Results: Our analysis included 31 802 patient visits treated by 185 physicians. The average patient age was 37.8 years with 64.3% being female and the majority triaged as CTAS 3 (82.5%). On average 24% of these visits were treated with IV therapies; 90th percentile; 34%. For physicians seeing in excess of 100 cases, the variation in IV therapy use ranged from 1% to 47%. Patients receiving IV therapies demonstrated a 44% greater average LOS (6.2 hours vs 4.3 hours) and those receiving IV therapies had higher 7-day ED revisit rates (12.0% vs 8.8%) as well as 7-day ED revisits resulting in readmission (2.4% vs 1.0%). 'mso-spacerun:yes'> Secondary outcomes were a comparison of ED LOS, ED revisits at 7 days and ED revisits resulting in admission at 7 days for the IV and non-IV groups. Conclusion: This is the first study to examine physician preference for the use of IV therapies in a low-acuity population and has demonstrated in excess of a 47-fold variation between both extremes of use. Reducing practice variation in this area of ED care by standardizing indications for IV therapies could result in more rational resource utilization and improved throughput.

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to the emergency department. Without anticoagulation, AFF increases stroke risk; individuals with paroxysmal AFF have a similar prognosis. A coordinated ED AFF electronic order-set and management pathway was developed at our institution. The primary objective of this study was to measure rates of appropriate anticoagulation (AAC) on discharge from the ED for patients presenting with AFF not previously on antithrombotic or anticoagulant medications. Secondary objectives included comparison of the following outcomes pre and post-pathway (PRE & POST): AFF Clinic referral rates, ED return rates, and mortality. Methods: This was a retrospective case series of patients presenting to our quarternary care ED with AFF pre and post AFF pathway implementation. Cases were identified using an administrative database covering 120 000 annual ED visits. Trained research assistants and the primary investigator extracted data from the electronic medical record. 20% of all charts were double collected to ensure accuracy (k=0.85). Descriptive variables were described using counts, means, medians and confidence intervals. Chi-square statistics of dependent samples were calculated for the primary outcome. Results: We examined 307 cases of AFF presenting to our ED (n=130 PRE; n=177 POST). Demographic variables were similar PRE and POST: mean age (66.0 [95%CI 63.8-68.3] PRE; 65.0 [63.0-67.0] POST), % male (59.2% PRE; 59.3% POST), presenting rhythm (66.2% A.fib [58.0-74.3] A. flutter 29.2% [21.4-37.0] PRE; 61.0% A.fib [53.8-68.1] A. flutter 17.5% [11.9-23.1] POST), and CHADS2VASC score (2.1 [1.8-2.4] PRE; 1.9 [1.7-2.1] POST). The rate of AAC rose from 39.1% PRE to 77.8% POST (P < 0.01). AFF clinic referral rates increased from 16.9% PRE to 25.4% POST (not significant). ED return rates within 30 days for AFF, CHF, major bleeding and CVA were unchanged. 30 day mortality rates were not statistically different (1.5% PRE vs. 2.8% POST). Conclusion: The implementation of a coordinated ED AFF pathway was associated with significant improvements in the proportion of patients discharged with appropriate anticoagulation who had not previously been on antithrombotic or anticoagulant medications. ED return rates and mortality did not change significantly.

Introduction: Cardiopulmonary resuscitation (CPR) quality assurance and research has traditionally been limited to the first five minutes of resuscitation due to significant costs in time, resources and personnel from manual data abstraction. Moreover, CPR quality can be affected during prolonged resuscitations, which represents significant knowledge gaps. The objective of this study was to develop a software program to help automate the abstraction of CPR quality data from electronic defibrillators. Methods: We developed a software program to facilitate and help automate data abstraction from electronic defibrillator files for entire resuscitation episodes. Internal validation of the software program was performed on 50 randomly selected cardiac arrest cases with resuscitation durations of up to 60 minutes. CPR quality data variables such as number of ventilations, number of compressions, minute compression rate, minute compression depth, minute compression fraction, minute end-tidal CO2, were manually abstracted independently by two trained data abstractors and by the automated software program. Error rates and the time needed for data abstraction were measured. Results: A total of 9826 data points were abstracted. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean time ± SD needed for manual data abstraction was 20.3 ± 2.7 minutes compared to 5.3 ± 1.4 minutes using the software program (p=0.003). Conclusion: Our CPR quality data abstraction software was 100% accurate in abstracting CPR quality data for complete resuscitation episodes and showed a significant reduction in data abstraction duration. This software will enable quality assurance programs and future cardiac arrest studies to evaluate the impact of CPR quality during prolonged resuscitations.

Introduction: Accurate and efficient interpretation of prehospital 12-lead electrocardiogram (ECG) in patients with suspected ST-segment elevation myocardial infarction (STEMI) can improve outcomes, especially in rural regions. In the Chaudière-Appalaches region, Quebec, a prehospital serial 12-lead ECG monitoring system is used for remote interpretation of ECG abnormalities by emergency physicians via a telemedicine platform, the Unité de Coordination Clinique des Soins Préhospitaliers d'Urgence (UCCSPU). The objective of the study was to evaluate the use of serial monitoring of dynamic ECG changes in patients with suspected STEMI during emergency medical services (EMS) transport. Methods: A retrospective cohort study with suspected STEMI patients monitored with prehospital serial ECGs was performed from August 2006 to December 2013. The data was extracted from UCCSPU clinical databases and verified by an emergency physician supervisor. During EMS transport, the serial ECG monitoring system automatically produced and transmitted every 2 minutes a 12-lead ECG without artefacts. STEMI criteria were based on the Third Universal Definition of Myocardial Infarction. Dynamic ECG change was defined as an ST-segment elevation or depression that meets diagnostic criteria (eg. initial non STEMI (NSTEMI) changing to STEMI and vice versa). Results: Among the 752 patients identified with suspected STEMI, 728 (96.8%) were included in the study due to missing data. The majority (614/728; 84.3%) had a consistent ST segment without significant dynamic changes throughout transport, of which 521 were identified as STEMI and 93 as NSTEMI. The remaining 114 patients (15.7%) had dynamic ECG changes: 41 (36%) evolved from NSTEMI to STEMI, 40 (35.1%) changed from STEMI to NSTEMI, and 33 (28.9%) had more than one dynamic ST-segment change. Overall, 59 patients (8.1%) had a final STEMI ECG diagnosis after an initial NSTEMI ECG interpretation. Conclusion: In this study, the serial ECG system enabled the remote diagnosis of STEMI in 8.1% of patients during EMS transport following an initial NSTEMI diagnosis. Serial monitoring of dynamic changes can allow for more rapid diversion to primary percutaneous coronary intervention facilities, potentially improving patient outcomes. Further studies are needed to evaluate the clinical impact, and costs and benefits of implementing this technology.

Introduction: Our national study of rural EDs showed they have limited access to CT scans, ICU, and most specialities, while Level 1 and Level 2 trauma centers are on average 300 km away. However, equivalent information on Northern/remote EDs is scarce. Objectives: This pilot study aimed to: 1) describe local access to services; and 2) mobilize citizens, decision-makers and healthcare professionals to envisage solutions to improving emergency care in a Northern/remote hospital. Methods: This descriptive, qualitative study was performed in a northern ED in Quebec. The head nurse received a prevalidated questionnaire about access to specific services, ED and patient characteristics (Objective 1). Focus groups (5) and individual interviews (11) were conducted with citizens/patients, decision-makers, physicians, nurses, paramedics, pharmacists, and mental health workers (Objective 2). Descriptive statistics are reported as means, medians and percentages for Objective 1. A thematic analysis was conducted for Objective 2. Results: Objective 1: The city (population 2875) is a mining community 962 km from Quebec City. The 2010 annual ED census was 6692. Proportions of patient visits at triage levels 1-5 were 0.2%, 3.2%, 13.4%, 25.4% and 56.7% respectively. The ED was staffed by one physician and two nurses per shift. The hospital had 24/7 access to basic X-ray and laboratory but no local access to speciality care, ICU, CT scan or ultrasound, with nearest services 28 km away. Objective 2: Analysis of qualitative data highlighted concerns for personal safety; telecommunication problems; lengthy transports; limited access to in-service training, advanced imaging, and consultants; and recruitment and retention difficulties. Solutions included pre-hospital training, telemedicine, protocols, and networking with academic centers/medical schools, North Shore colleagues, and Labrador City Hospital. Conclusion: This isolated northern ED has limited access to services. Valuable qualitative information obtained enabled us to better understand the challenges and explore solutions towards improving Northern/remote emergency care.

Introduction: Clear paramedic-physician telecommunications (patches) are critical in systems utilizing on-line medical control. In systems using extensive medical directives individual paramedics patch infrequently. Investigations of specific problem calls indicated that communication problems were more common than believed. Existing literature on this topic is sparse. This project is a quality assurance exercise undertaken to understand the extent and nature of problems in paramedic-physician telecommunications Methods: Retrospective analysis of anonymized transcriptions made from MP3 audio files recorded as part of normal operating procedures by the Central Ambulance Communication Centre during January-March 2014. All calls where telecommunication occurred between paramedics from 4 ambulance services and base hospital physicians providing on-line medical oversight during ambulance calls were included. Transcripts were read multiple times and data extracted onto spreadsheets for frequency analysis. Further thematic framework analysis of emergent themes was done. Results: All 42 patches were transcribed and used for analysis. 36 (85.7%) were for termination of resuscitation orders, 4 (9.5%) were for advice, and 2 (4.8%) were for orders not covered by medical directives. Communication problems were identified in 40 (95.2%) patches. Most had multiple problems. These included disconnections (23.8%), difficulty hearing one another (40.5%) - indicated by phrases such as “sorry?” “what?”, “I can’t hear you” - or caused by individuals interrupting each other (83.3%), and talking simultaneously (47.6%). Signaling the end of “talk turns” - such as “10-4” or “over” - was never used. Instead, terms like “yah” and “OK” were used. When communication went awry, time was spent trying to repair the mis/poor communication. This led to repeating information or attempting to ‘sell’ the case by providing information unnecessary for decision making - such as during a request for termination of resuscitation, “there is vomit on the floor”. Conclusion: Paramedic-physician telecommunication problems were extremely common. They involved technical (mechanical problems) and human factors (disorganized radio ‘technique’). The high incidence of telecommunication problems identified is concerning. Critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Further study of these issues is warranted.

Introduction: A hot, painful, swollen joint is a common presentation to the emergency department. Of the potential etiologies, septic arthritis (SA) is the most devastating. Prompt diagnosis and treatment are essential to improve outcomes. Both culture proven and clinically suspected SA are thought to have the same prognosis, with similar morbidity and mortality estimates. No clinical exam or serum lab finding has the sensitivity or specificity to diagnose or exclude SA. Instead, diagnosis relies mainly on joint aspiration and synovial fluid analysis. A synovial white blood cell count (sWBC) greater than 50,000 cells/microliter is suggestive of SA and organisms seen on gram stain or growing in culture effectively makes the diagnosis. However, culture and gram stain are positive in only 67% and 50% of cases respectively. The objective of this study was to analyze the accuracy of synovial fluid analysis in our local practice environment. Methods: All those encounters with diagnoses related to SA at four adult emergency departments in Calgary between 2013-2014 were reviewed. Hospital records were analyzed for synovial analysis, antibiotic usage and surgical procedures. Results: Of 286 encounters, 87 were determined to satisfy the definition for SA in that culture was positive, gram stain was positive or clinical findings lead to treatment with antibiotics and/or surgical intervention. Gram stain was positive in 22% of cases with cultures positive in 51% of patients. sWBC were less than 50000 in 55% of cases and less than 25000 in 24% of cases. Of 88 gram stains performed, 28% were negative but had positive culture. All positive gram stains were associated with positive cultures. Conclusion: Culture, gram stain and sWBC of patients diagnosed with SA in Calgary show differences compared with the published literature. In Calgary, the majority of SA diagnoses were made clinically. The sWBC is central to making the diagnosis. Interestingly, 55% of patients diagnosed with SA had a count less than 50,000. It remains unclear what features of history, physical exam, imaging and lab analysis lead to the diagnosis of SA in these cases. Future studies will focus on these outliers to see if a more appropriate diagnostic algorithm would be useful in Calgary. Collaboration between infectious disease specialists, orthopedics, and emergency departments guided by local data is needed to ensure accurate and timely diagnosis.

Introduction: Current guidelines do not recommend the routine use of urinary cultures in the management of uncomplicated urinary tract infection (UTI) in premenopausal, non-pregnant women. Complicating factors include atypical presentation, structural abnormalities or recent recurrent infection/antibiotic use. The objective of this study was to determine the number of urine cultures ordered for women who presented to the emergency department (ED) with symptoms of uncomplicated UTI, and whether a culture result impacted subsequent management. Methods: This was a retrospective chart review of women aged 18-39 presenting to one of two academic EDs with a discharge diagnosis of uncomplicated UTI from Jan-Dec 2014. Patients were excluded if any of the following were documented: pregnancy, fever, immunocompromised state, diabetes mellitus, absence of lower urinary tract symptoms, ED administration of intravenous antibiotics, a previous UTI treated with antibiotics in the last 90 days, two weeks post-partum or post-instrumentation. Results: Of the 512 charts included in the analysis, 494 (96.5%) patients had a urinalysis, of which 463 (93.7%) had positive leukocyte esterase and 90 (18.2%) had positive nitrites. 370 patients (72.3%) had urine cultures performed, of which 236 (63.8%) were positive. 505 (98.6%) patients received antibiotics (53.9% Macrobid; 22.6% Ciprofloxacin; 15.0% Septra; 6.7% other; 1.8% not documented). 7 (1.9%) cultures grew organisms resistant to the prescribed antibiotic; 2 (0.5%) patients received new prescriptions. Conclusion: For the majority of young female patients with uncomplicated UTI, urine cultures did not change management. Almost all of these patients had a positive leukocyte esterase and were treated with antibiotics, yet approximately 40% of the patients tested did not return positive urine cultures, suggesting that better algorithms for the diagnosis of UTI in the ED are required. Unnecessary treatment with antibiotics is expensive, contributes to the development of multidrug resistant organisms, and exposes the patient to the unnecessary risks of possible allergic reactions, drug interactions and side effects.