Introduction: Hip fractures affect over 30,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. Previous studies have shown that regional anesthesia is the optimal pain management strategy for hip fracture patients and has been shown to independently reduce the rate, severity and duration of delirium. However, very few emergency physicians (EPs) have the necessary training and experience to use regional anesthesia for hip fracture in the emergency department (ED). The objective of this study was to determine the number of femoral nerve blocks performed within the ED for the management of hip fracture patients. Methods: This was a retrospective chart review of patients aged 65 years and older, presenting to an academic ED (annual census 60,000) with a discharge diagnosis of hip fracture from January 1st 2014 to July 31st 2015. Results: Of the 243 hip fractures included in this study, mean (SD) age was 82.9 (8.2) years and 187 (77.0%) were female. The majority (214, 88.1%) of patients arrived to the ED by ambulance and 182 (74.9%) were categorized as CTAS 3. The most common analgesics used in the ED were intravenous (IV) hydromorphone (51.4%), IV morphine (32.1%), or dual therapy with both IV hydromorphone and IV morphine (4.9%). Femoral nerve blocks were initiated for 13 (5.3%) patients and successfully completed in 12 (4.9%) patients in the ED. Median (IQR) ED and hospital length of stay was 5.0 (3.7, 6.6) hours and 6.0 (4.1, 10.2) days, respectively. Forty-three (17.7%) patients experienced in-hospital acute delirium. Conclusion: Despite evidence to suggest regional anesthesia may be the optimal pain management strategy for hip fracture patients, the use of femoral nerve blocks in the ED remains low. Future research should attempt to elucidate barriers to use of this procedure by emergency physicians.

Introduction: The accurate interpretation of potential ST-segment elevations on electrocardiograms (ECGs) to diagnose acute myocardial infarction (MI) is a critical competency for emergency physicians (EPs) and cardiologists. There is conflicting evidence on the diagnostic accuracy of EPs and cardiologists interpreting potential STEMI ECGs. Methods: We conducted a web-based assessment of the diagnostic accuracy of potential STEMI ECGs of Canadian EPs and cardiologists. They were identified using the membership lists of the Canadian Association of Emergency Physicians and the academic departments of cardiology at Canadian medical schools. When provided with 20 ECGs of confirmed STEMI patients, EPs and cardiologists were asked to provide a binary Yes/No answer to the question, “In a patient with ischemic chest pain, does this ECG represent a STEMI?” EPs and cardiologists were blinded to the correct answers while completing the web-based assessment. Descriptive statistics were used to described frequencies and counts. Analysis using Rasch Measurement Theory was used to explore the relationship between correct interpretation of ECGs and predictive variables such as age, years in practice or type of practice. Results: Two hundred and fifty EPs and 30 cardiologists (n=280) responded to our survey (total response rate 25%). Average years in practice were 12.5 for EPs (SD 10.6; median 10) and 14.6 for cardiologists (SD 10.6; median 11); 52% of EPs and 93% of cardiologists practiced in an academic setting. Seven of the cardiologists were interventionalists, while 47.6% of EPs and 97% of cardiologists practiced at hospitals with 24-hour catheterization capability. The diagnostic accuracy of EPs for identifying STEMI ECGs was 75% (SD 15%); cardiologists’ accuracy was 76% (SD 15.5%). The ability to correctly interpret the ECGs was independent of age, years in practice, or type of practice (community vs academic). Conclusion: EPs and cardiologists display similar diagnostic accuracy for interpreting STEMI ECGs, regardless of age, years in practice or type of practice. The findings of our study suggest the need for focused ECG education for both EPs and cardiologists.

Introduction: Appendicitis is a common surgical condition that frequently requires patients to undergo diagnostic imaging. Abdominal computed tomography is the gold standard imaging technique for the diagnosis of appendicitis, but exposes patients to radiation. Ultrasound offers an alternate radiation-free imaging modality for appendicitis. However, the availability of ultrasound during off-hours is limited in many Emergency departments (EDs). Clinician performed point-of-care ultrasound (POCUS) is increasingly used by emergency physicians as a bedside tool to evaluate suspected appendicitis. The purpose of this study is to evaluate the test characteristics of emergency physician performed POCUS to diagnose appendicitis in a Canadian ED. Methods: A pragmatic, retrospective chart review was performed on all patients for whom a POCUS was performed to diagnose appendicitis at St. Joseph’s Healthcare Hamilton in Ontario from December 1, 2010 to December 4, 2015. All POCUS scans were performed by physicians with Registered Diagnostic Medical Sonographer (RDMS) credentials or resident physicians undergoing POCUS fellowship training. All scans were over-read by RDMS credentialed faculty and subject to a rigorous quality assurance (QA) process. POCUS findings and patient outcomes were reported. Results: A total of 90 patients were included in the study. 24 patients were diagnosed with appendicitis on POCUS. Ultimately, 18 were diagnosed with appendicitis through formal imaging, laparoscopy, and pathology. The sensitivity and specificity for POCUS to diagnose appendicitis was found to be 69.2% (95% CI, 48.1%-84.9%) and 90.6% (95% CI, 80.0%-96.1%) respectively. Conclusion: Bedside ultrasound is a reliable imaging modality for ruling in acute appendicitis. In cases where POCUS is negative or indeterminate for appendicitis, further imaging should be obtained as clinical suspicion warrants. The use of POCUS has the potential to reduce patient exposure to ionizing radiation and decrease the costs of obtaining CT scans, while hastening the process of achieving definitive management through earlier surgical consultation.

Introduction: Resuscitation of a trauma patient requires a multidisciplinary team to perform in a dynamic, high-stakes environment. Error is ubiquitous in trauma care, often related to latent safety threats (LSTs) - previously unrecognized threats that can materialize at any time. In-situ simulation (ISS) allows a team to practice in their authentic environment while providing an opportunistic milieu to explore critical events and uncover LSTs that impact patient safety. Methods: At a Canadian Level 1 trauma centre, regular, unannounced trauma ISSs were conducted and video-recorded. A retrospective chart review of adverse events or unexpected deaths informed ISS scenario design. Each session began with a trauma team activation. The on-duty trauma team arrived in the trauma bay and provided care as they would for a real patient. Semi-structured debriefing with participant-driven LST identification and ethnographic observation occurred in real time. A framework analysis using video review was conducted by human factors experts to identify and evaluate LSTs. Feasibility was measured by the impact on ED workflow, interruptions of clinical care and participant feedback. Results: Six multidisciplinary, high-fidelity, ISS sessions were conducted and 70 multidisciplinary staff and trainees participated in at least one session. Using a framework analysis, LSTs were identified and categorized into seven themes that relate to clinical tasks, equipment, team communication, and participant workflow. LSTs were quantified and prioritized using a hazard scoring matrix. ISS was effectively implemented during both low and high patient volume situations. No critical interruptions in patient care were identified during ISS sessions and overall participant feedback was positive. Conclusion: This novel, multidisciplinary ISS trauma training program integrated risk-informed simulation cases with human factors analysis to identify LSTs. ISS offers an opportunity for an iterative review process of high-risk situations beyond the traditional morbidity and mortality rounds; rather than waiting for an actual case to generate discussion and review, we prophylactically examined critical situations and processes. Findings form a framework for recommendations about improvements in equipment, environment layout, workflow, system processes, effective team training, and ultimately patient safety.

Introduction: Concussion is a common emergency department (ED) presentation. Most patients improve with expectant management. A subset with risk factors for post-concussion syndrome (PCS) may require closer outpatient follow-up. A novel emergency department (ED)/head injury clinic (HIC) triaging system has been created to allow concussed patients rapid access to educational information and specialized consultant services. This system has been well received by patients and physicians alike; however, objective measures are needed to determine if this system ultimately decreases excessive healthcare utilization (HCU) and improves symptom management of PCS. Methods: Single centered prospective observational study. Control population of 42 mTBI patients referred to the HIC through the Ontario Acquired Brain Injury (ABI) Network within 3-12 months of injury. These patients have received little concussion education or treatment and will be compared to 50 concussion patients seen in the ED and HIC. Rivermead scores, a validated likert scale of PCS symptoms (1-4, maximum score of 64) and HCU (patient reported number of healthcare visits post injury) will be collected on their initial clinic visit and subsequent follow up phone interview. Results: Control ABI network patients were 50% male, mean age 40 yrs (18-90, ± 16.3) while 83% (35/42) reported >1 subsequent visit to ED or family physician and 39% (16/42) visited neurologist. Mean Rivermead Score was 32.6 (7-58, ± 12). Conclusion: A significant proportion of control patients utilized multiple healthcare resources and were still symptomatic 3-6 months following injury. Data collection is currently ongoing to determine if rapid outpatient follow-up and education decreases HCU and PCS symptoms.

Introduction: Any large-scale disaster may place a hospital system in a precarious position. Planning is fundamental to facilitate an equitable process for allocating scarce critical care resources, yet there is a paucity of literature guiding protocol development, and few Canadian hospitals have done this planning. We performed a scoping review of the available literature, and used this data to develop a hospital-wide policy to guide critical care resource allocation as part of the hospital emergency management planning process. Methods: A primary search of MEDLINE (1946-2015), EMBASE (1980-2015), Disaster Lit (2002-2010) and Pubmed focusing on a priori criteria was completed. A secondary search of the grey literature served to increase sensitivity and rigor. Two independent reviewers manually reviewed the citations, and selected eligible abstracts for full-text. Qualitative thematic analysis was undertaken of the selected articles. The results then informed the development of a hospital-wide policy and protocol to guide critical care resource allocation. Results: The search identified 832 citations; 134 papers were reviewed and 11 selected for qualitative analysis. All included papers were expert opinion and reviews. All suggested that an ethical framework be used; eight discussed this in detail. Ten recommended allocating a triage team to implement the protocol. Nine papers recommended specific resource allocation protocols with inclusion/exclusion criteria, physiologic scores, and reassessment at varying time intervals (12-120 hours). Conclusion: Effective planning, prior to a disaster, is critical to saving as many lives as possible. Based on our scoping review, we have developed a hospital-wide protocol that incorporates ethical principles and clear inclusion and exclusion criteria, to help avoid inequity and promote transparent decision-making. Next steps include a public consultation process and review, prior to implementation testing and educational roll-out.

Introduction: Although many uncomplicated pediatric fractures do not require routine long-term follow-up with an orthopedic surgeon, practitioners with limited experience dealing with pediatrics fractures will often defer to a strategy of frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the healthcare system. Methods: A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of clavicle fractures was performed. Results: Three hundred and forty patients (227 males, 113 females) with an average age of 8.1 (range 0.1-17.8) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.1 (±1.3). The mean number of radiology department appointments was 1.8 (±1.3) where patients received a mean number of 4.2 (±3.0) radiographs. Complications were minimal; 2 refractures in our series and no known cases of non-union. All patients achieved clinical and radiographic union and returned to sport after fracture healing. Conclusion: Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary-care physician, then routine clinical or radiographic follow up is unnecessary. Our paediatric clavicle fracture pathway will reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients’ families without jeopardizing patient outcomes.

Introduction: In the clinical settings, emergency physicians are faced with situations that require multitasking such as interacting with other team members, documentation and utilization of computer resources whiles ensuring competency on a particular trauma skill. The purpose of this study was to assess the effect of multitasking on cognitive load when learning a common trauma skill. Methods: Sixteen students who had no previous experience with the one-handed square knot were randomly assigned to one of the two groups: practice and non-practice groups. A pre-recorded instructional video of a one-hand knot tying was presented to all participants. Next, the practice group completed a single session of 10 trials of the one-hand knot tying using a benchtop simulator, while the non-practice group did not. All returned a week later for a transfer task on a different simulator. On trials 1, 4, 7,10 and during the transfer performance the participants performed under dual task conditions, where they were asked to focus on the knot-tying task, but also to react as fast as possible to the illumination of an incandescent light bulb by pressing a foot pedal. Subjective ratings of mental effort, and reaction time to the visual stimulus were used as indices of cognitive load. Results: A repeated measure ANOVA showed a significant effect of dual task on subjective measure of mental effort (F(4, 28) = 10.35, p = .001, ω = .60) and reaction time (F(4, 28) = 7.93, p = .001, ω = .53), with plots indicating cognitive load plateaued by the 7th trial. Conclusion: These findings highlights the number of trials necessary to attain a level of proficiency in a basic trauma skill such as the one-hand knot tying, ease the level of cognitive load and possibly enhance transfer to more challenging tasks.

Introduction: Croup is one of the most common childhood respiratory illnesses, affecting more than 80,000 Canadian children per year. Early dexamethasone administration in croup can reduce admission rates and length of stay (LOS), as well as return visits to the emergency department (ED). Pre-hospital emergency medical services (EMS) teams in Edmonton administer dexamethasone to children with croup. The objectives of this study were to (a) assess the clinical impact of pre-hospital administration of dexamethasone to children with croup and (b) compare clinical outcomes of these patients to those who did not receive their first dose of dexamethasone via the EMS providers. Methods: This study was a retrospective medical record review that included children between 6 months and 6 years of age who were brought via EMS to the Stollery Children’s Hospital ED with a final diagnosis of croup, between January 1st 2010 and December 31st 2012. Data were collected regarding pre-hospital presentation and management, ED presentation and management, ED LOS and final disposition, and patient demographics. Results: 188 patients were enrolled, 35.1% (66/188) of whom received a pre-hospital diagnosis of croup. The mean age of the participants was 32.96 months (SD±17.18). Overall, 10.6% patients (20/188) were given dexamethasone in the pre-hospital setting, while 30.3% patients (57/188) were given nebulized epinephrine by EMS. Out of the 66 patients with a pre-hospital diagnosis of croup, 10.6% (n=7) were given dexamethasone by EMS. In the ED, dexamethasone was administered to 88.3% of patients (166/188) while 56/188 participants (29.8%) received nebulized epinephrine. There was no statistically significant difference in ED LOS stay between those who received pre-hospital dexamethasone (2.6 hours, SD±1.6, n=18) and those who did not (3.3 hours, SD±2.7, n=159). The number of in-hospital epinephrine doses per patient was influenced by the administration of pre-hospital dexamethasone (p=0.010). Conclusion: Pre-hospital administration of dexamethasone likely influences the severity and short-term persistence of croup symptoms, as evidenced by less epinephrine use in the ED. Contrary to current EMS guidelines, very few patients with a pre-hospital diagnosis of croup received dexamethasone by EMS personnel. This likely represents a missed opportunity to decrease the severity of the patients’ disease.

Introduction: Measures of satisfaction are essential to understanding patient experience, and pain management. Currently, there are no validated tools to quantify children’s satisfaction. To develop such a tool, we must first understand which words children use to communicate satisfaction. Our objectives were to (A) to identify the words commonly used by children of different ages to communicate satisfaction, in general, and in the context of pain management, and (B) to determine if this vocabulary is similar to that used by their caregiver. Methods: A qualitative study of 105 children-parent pairs, aged 3-16 years, who were evaluated at a pediatric emergency department (PED) from July-November 2014 was conducted. Children were interviewed using a semi-structured format of ten open-ended questions. They were asked to describe their feelings when 1) they received something they wanted/needed, 2) their expectations were met or not met in the ED, and 3) their pain was or was not relieved. A written survey was also completed by the caregiver. Interviews were transcribed and grounded theory was employed for data coding and analysis. Results: 105 child interviews were completed (n=53 female, mean age 9.91 SD 3.71, age range 4-16). 105 caregiver surveys were completed (n=80 female). “Good”, “better,” and “happy” were most commonly used by all children (n=99) to express satisfaction with pain management (27%, 21% and 22%, respectively), with PED care (31%, 14% and 33%) and in general (13%, 5% and 49%). Children (n=99) used the words “sad”, “bad,” and “not good” to communicate dissatisfaction with pain management (21%, 7% and 11% respectively), and with PED care (21%, 13% and 12%, respectively). Only 55% of children understood the meaning of the word ‘satisfaction’. Children used words that were similar to their caregiver 14% of the time. Conclusion: The word “satisfaction” should not be used to communicate with children in the emergency department, as many lack understanding of the term. The vocabulary that children use to describe satisfaction does not largely vary with context and involves simpler words than their parents. Caregiver vocabulary should not be used as a surrogate for pediatric patients. This study will inform the development of a validated tool to measure children’s satisfaction with pain management.

Introduction: Frailty is associated with mobility & physical impairment in seniors with minor injuries. Serum biomarkers have also been suggested as potential markers of these impairments in clinical studies. No study has examined if serum biomarkers could contribute to the diagnosis of frailty in seniors with minor injuries. Objectives: To explore the association between several serum biomarkers (Ferritin, Creatinine, Vitamin D, Albumin, Glucose, Estradiol, Testosterone, Thyroid Stimulating Hormone (TSH), Insulin-Growth Factor (IGF-1) C-reactive protein (CRP)) and frailty level in seniors treated in emergency department (ED) for minor injuries. Methods: Cross-sectional study within the larger CETI cohort. It includes 142 seniors discharged home from 4 EDs after treatment of minor injuries. Their frailty status was measured by the Canadian Study of Health & Aging-Clinical Frailty Scale (CSHA-CFS). Biomarkers were obtained from blood samples. Pearson’s correlations (r) were performed to examine the relation between serum biomarkers and frailty levels. Partial correlation controlled for age and sex, were also performed. Results: Due to inclusion criteria, no patient was severely frail. Overall, these preliminary analyses seem to indicate that robust patients tended to have lower Glucose & Vitamin D levels (-0.264 ≤ r ≤ -0.230; p < 0.05), higher Estradiol (r = 0,230; p < 0.05) & Testosterone (r = 0,295; p < 0.05), while prefrail/frail patients tended to have higher Glucose & Vitamin D levels (0,235 ≤ r ≤ 0,238; p < 0.05), lower Estradiol levels (r = -0,235; p < 0.05) & more elevated Ferritin levels. Due to the small number of patients, controlling for age and sex lead to non-significant results of the most associations. Conclusion: Pre-frail/frail seniors presenting to EDs with minor injuries tend to have higher Ferritin, Glucose & Vitamin D levels as well as lower sexual hormones levels than robust individuals. Larger samples are needed in order to elucidate which biomarkers could be most useful to identify frail seniors needing clinical attention and to assess a possible association with mobility impairments in this population.

Introduction: Chronic pain and substance misuse are complex chronic illness that are subject to prejudice, misinterpretation and cultural biases. They require a broad, multi-disciplined approach if they are to be effectively managed. Barrier’s to effective care in the emergency department include our reliance on pain scales alone to effectively triage and manage chronic pain, differing philosophy’s and attitudes regarding the appropriate use of high risk pain pharmacology including opioids and confusing classifications systems used to describe pain and problematic substance use which can often lead to further stigmatization and over medicating. Methods: The charts of thirteen patients with complex pain and problematic substance use who had more than 360 visits to a regional emergency department in one year were reviewed retrospectively and data collected regarding frequency of visits and disposition after the implementation of a comprehensive pain and addiction strategy from April 2011 to August 2015. Results: In the first year of implementation there was a 70% drop in the frequency of emergency department visits. Five patients (38%) required a comprehensive pain plan. Six agreed (46%) to a direct referral to our mental health, addiction and chronic pain services. Two patients (15%) were lost to follow-up. Review of the electronic record to track patient visits to provincial emergency departments did not show an increase in visits to other facilities within the province. Review of visits in 2015 show a 97% drop in the frequency of visits. Family Physicians in the community did not report an increase in the frequency of patient visits as a direct result of the implementation of this strategy nor was there an increase in complaints to administration regarding ineffective pain management. Conclusion: Although survey numbers are low it suggests that a framework for the management of complex pain and substance use disorders can be successfully implemented in the emergency department improving timely access to appropriate management and resources for patients based on best practice to address their complex needs.

Introduction: The right to live is the supreme human right and according to Article 3 of the Universal declaration of human rights everyone has a right to life, liberty and security. In Karachi, Pakistan huge numbers of health care professionals (HCP) have been subjected to violence inclusive of money extortion, kidnapping, mental & physical torture, murders etc. A recent study from Karachi’s four major hospitals reported that 72.5% of HCP have experienced abuse (verbal and physical) in the past 12 months. The goal of this study was to develop strategies for preventing violence against health care after collecting baseline data. The objectives of the study were to: Identify the magnitude, threshold and impact of violence against HCPs. Methods: This was a mixed methods study design with a QUAN-QUAL approach. Structured questionnaire was used after pilot testing and filled by the surveyors. Focus group discussion and In-depth interviews were conducted with HCPs, NGOs, Law enforcement agencies, ambulance services, hospital administrators and LHW programs. Frequencies and proportions were compared for different cadres of HCPs for the quantitative data analysis. Thematic content analysis with inductive and deductive reasoning was used for analysing qualitative data. Results: Data on 822 HCPs revealed that 33% had faced violence and 49 % had experienced it, 89% was verbal and 43% was physical abuse, 2% had died and 22% were injured. Ambulance services and physicians were the most common victims of violence. The main reasons were grouped as institutional, behavioral (victims and perpetrators) and general situation of the city. There is high acceptance of violence among HCPs and lack of training in dealing with it was the most common reason given. Sequlae included effects on victim, family, institution and the reporting agencies. The final paper will have complete details on the baseline and the recommendations proposed by the stakeholders. Conclusion: Violence faced by HCP’s is a multifactorial complex issue. There is a dire need to design interventions which can help in addressing the behavioral, Institutional and sociopolitical factors promoting violence among HCP’s. The interventions based on recommendations by the respondents have been developed and implementation has started as a pilot in the city of Karachi.

Introduction: In June 2012, the federal government made cuts to the Interim Federal Health (IFH) Program that reduced or eliminated health insurance for refugee claimants in Canada. The purpose of this study was to examine the effect of the cuts on emergency department (ED) use among patients claiming IFH benefits. Methods: We conducted a health records review at two tertiary care EDs in Ottawa. We reviewed all ED visits wherein an IFH claim was made at triage, for 18 months before and 18 months after the changes to the program on June 30, 2012 (2011-2013). Claims made before and after the cuts were compared in terms of basic demographics, chief presenting complaints, acuity, diagnosis, presence of primary care, and financial status of the claim. Results: There were a total of 612 IFH claims made in the ED from 2011-2013. The demographic characteristics, acuity of presentation and discharge diagnosis were similar during both the before and after periods. Overall, 28.6% fewer claims were made under the IFH program after the cuts. Of the claims made, significantly more were rejected after the cuts than before (13.7% after vs. 3.9% before, p<0.05). The majority (75.0%) of rejected claims have not been paid by patients. Fewer patients after the cuts indicated that they had a family physician (20.4% after vs. 30% before, p<0.05) yet a higher proportion of these patients were still advised to follow up with their family doctor during the after period (67.2% after vs. 41.8% before, p<0.05). Conclusion: A higher proportion of both rejected and subsequently unpaid claims after the IFH cuts in June 2012 represents a potential barrier to emergency medical care, as well as a new financial burden to be shouldered by patients and hospitals. A reduction in IFH claims in the ED and a reduction in the number of patients with access to a family physician also suggests inadequate care for this population. Yet, the lack of primary care was not reflected in the follow-up advice offered by ED physicians to patients.

Introduction: Studies have shown that First Nations patients have poorer health outcomes than non-First Nations patients. This has raised concerns that they receive unequal treatment from the health care system in general and the Emergency Department (ED) in particular. We sought to determine if there was such a difference and what it was so that it could be corrected. Methods: We performed a retrospective chart review to compare the care received by status First Nations and non-First Nations patients presenting to two hospital ED’s (Royal University Hospital and St. Paul’s Hospital) in Saskatoon, Saskatchewan with the chief complaint of abdominal pain and a Canadian Triage and Acuity Scale (CTAS) score of three. A total of 200 charts were reviewed (100 from each site and 100 from each group) by two medical students. One student was involved in blinding the charts; the other was responsible for analyzing the charts. Identifying information on the charts was redacted to blind the reviewer to the patient’s group during the chart review. Data extracted from each chart included time to doctor, time to analgesia given, length of stay, referral for consultation, blood work, imaging, bounce backs, reassessment, physical and history exam, and final disposition. This data will then be compared between the two population groups to find if there is equality in care given. Results: Data is currently being analyzed and will be available for presentation at CAEP 2016. Conclusion: The goal of our health care system is to provide the same level of excellent care to every patient that arrives in the ED. If care is not being provided equitably to First Nations patients this must be identified for it to be addressed. This study aimed to determine whether disparities in care exist. If they are found subsequent research could be done to determine why these differences exist while at the same time working to minimize and eliminate them for the benefit of First Nations patients.

Introduction: Rural emergency departments (EDs) are an important gateway to care for the 20% of Canadians who live in rural areas. We recently reported that fewer than 15% of rural EDs in Canada have access to a CT scanner. Lack of CT scanners in rural hospitals can result in frequent inter-facility transfers and delays in diagnosing and treating life-threatening conditions. No recent study has examined this issue. Objective: With a future larger study in mind, we did a pilot assessment of inter-facility transfers for CT scans from one rural ED and evaluated the quality of the data and feasibility. Methods: This pilot study was part of our province-wide study on rural emergency care. Criteria were having 24/7 physician coverage and acute-care hospitalization beds. The hospital was also selected for its proximity and local interest. Two medical students collected data from hospital databases to determine annual number of ED visits, ED transfers, proportion of transfers for CT scans, reasons for examinations, and transfer times from April 1, 2010 to March 31, 2015. Descriptive statistics were reported as well as data quality and feasibility indicators. Results: For each year from 2010 to 2014, there was an average of 13,341 ED visits, 444 inter-facility transfers, and 125 CT scans. Over the five years an average of 28% of the inter-facility transfers were for CT scans, and the majority were abdominal CT scans. Inter-facility transfer data was 100% accessible through hospital databases but inter-facility transfer times and final diagnoses were not. Conclusion: More than a quarter of inter-facility transfers were for CT imaging. The limited electronic data in this Quebec rural ED precluded analysis of inter-facility times. While further cost-benefit analysis is required, preliminary data suggests local CTs may save time, money and lives.

Introduction: Nearly 12 million emergency department (ED) visits in the USA annually are related to a mental health and/or substance abuse condition. This is equivalent to 1 out of every 8 ED visits or 12.5 percent of all ED visits annually. States cut $5 billion in mental health services from 2009 to 2012. In the same period, the country eliminated at least 4,500 public psychiatric hospital beds. This has led to an increase in psychiatric boarding. Boarding consumes scarce ED resources and prolongs the amount of time that all patients must spend waiting for services. The aim of this study is to determine if being roomed next to a psychiatric patient affects patient satisfaction and perception of care. Methods: A survey consisting of 15 patient satisfaction questions was distributed to patients over a period of three months in the ED at a tertiary care center with >125,000 visits a year. Patients included were English-speaking adults (18 years or older) with an Emergency Severity Index of 3-5. Responses were analyzed with a chi-square across 2 groups with p-value of 0.05 considered as significant. Results: A convenience sample of 78 surveys was obtained. 40 surveys were completed by those roomed next to a patient with a psychiatric complaint and 38 surveys were completed by patients not roomed next to a patient being seen for a psychiatric complaint. For every satisfaction question asked, the patients placed away from mental health encounters gave significantly higher ratings than the patients roomed near psychiatric patients. Patients roomed next to psychiatric patients had a statistically significant decrease in satisfaction in nursing attentiveness, nursing promptness in responding to the call bell, attentiveness of the physician team, and of the overall encounter itself. All values were significant with all but one p-value being <0.01.There was no difference between the 2 groups with respect to gender, age range, reason for visit or wait time. Conclusion: This study suggests that patients being roomed next to a patient with a psychiatric complaint had significantly decreased patient satisfaction.

Introduction: The Canadian CT Head Rule (‘the rule’) is widely used across the country and its use is specifically recommended by Choosing Wisely Canada. Studies in Canadian hospitals have shown appropriate declines in CT scans when decision tools have been made readily available and useable at the point of care. Research into the implementation of the Canadian CT Head Rule in particular has shown that barriers to its use include an inability to accurately recall each criteria and forgetting to attempt to apply the rule altogether. In an attempt to provide our clinicians with effective access to the rule, we modified CT requisitions and order procedures to facilitate the use of the rule for every head CT in our emergency department (ED). Methods: A quality improvement (QI) approach was used to pilot, implement, and evaluate the modified CT requisition at our hospital. Several Plan-Do-Study-Act cycles involving stakeholders in the hospital resulted in iterative changes to the requisition leading to the implemented version. The new requisition required physicians to indicate which rules or exclusion criteria were met and this was made mandatory for all head CTs ordered. Demographic data was collected on all patients presenting to the ED on age, gender, CTAS level, disposition, and length of stay. Data on which exclusion criteria were appropriate, the rules met leading to CT scans, whether each requisition was used appropriately, and whether there was a significant injury found was collected for each patient receiving a head CT after implementation. Results: In our primary outcome (% of ED visits receiving a head CT), preliminary results have demonstrated a relative reduction in head CT ordering of 10.9%. Our study at completion is powered to detect a ~10% relative change in ordering behaviour, and a Chi square of the data to date yields a P-value of 0.0147. There are no significant differences in visit volume or any of the demographics collected to date. Final results including analysis are anticipated in March, 2016. Conclusion: Preliminary results on this simple, no-cost intervention are very promising. The reduction in head CTs ordered suggests that with mandated access to an easy-to-use, well validated decision tool, ED physicians have been able to confidently defer scans that have a very low risk of having any significant injury present, reducing cost, radiation exposure, and perhaps time in department.

Introduction: Hospitalization due to ambulatory care sensitive conditions (ACSC) is a proxy measure for access to primary care. Emergency medical services (EMS) are increasingly called when primary care cannot be accessed. A novel paramedic-nurse EMS Mobile Care Team (MCT) was implemented in an under-serviced community. The MCT responds in a non-transport unit to bookings from EMS, emergency and primary care and to low-acuity 911 calls in a defined geographic region. Our objective was to compare the prevalence of ACSC in ground ambulance (GA) responses before and after the introduction of the MCT. Methods: A cross-sectional analysis of GA and MCT patients with ACSC (determined by chief complaint, clinical impression, treatment protocol and medical history) one year pre- and one year post-MCT implementation was conducted for the period Oct. 1, 2012 to Sept. 30, 2014. Demographics were described. Predictors of ACSC were identified via logistic regression. Prevalence was compared with chi-squared analysis. Results: There were 975 calls pre- and 1208 GA/95 MCT calls post-MCT. ACSC in GA patients pre- and post-MCT was similar: n=122, 12.5% vs. n=185, 15.3%; p=0.06. ACSC in patients seen by EMS (GA plus MCT) increased in the post-period: 122 (12.5%) vs. 204 (15.7%) p=0.04. Pre vs post, GA calls differed by sex (p=0.007) but not age (65.38 ± 15.12 vs. 62.51 ± 20.48; p=0.16). Post-MCT, prevalence of specific ACSC increased for GA: hypertension (p<0.001) and congestive heart failure (p=0.04). MCT patients with ACSC were less likely to have a primary care provider compared to GA (90.2% and 87.6% vs. 63.2%; p=0.003, p=0.004). Conclusion: The prevalence of ACSC did not decrease for GA with the introduction of the MCT, but ACSC in the overall patient population served by EMS increased. It is possible more patients with ACSC call or are referred to EMS for the new MCT service. Given that MCT patients were less likely to have a primary care provider this may represent an increase in access to care, or a shift away from other emergency/episodic care. These associations must be further studied to inform the ideal utility of adding such services to EMS and healthcare systems.

Introduction: Variations of patient volumes in the ED according to days of the week and month of the year are well-established. Anecdotally, ED volumes follow ‘waves’ that correlate with previous days. Time-series models have traditionally been used in econometrics to develop financial models, but have been adapted in other fields, such as health informatics. This study uses a time-series approach to assess whether these impressions are valid. Methods: The daily volume of patients presenting to four emergency departments (ED) at the Nova Scotia Health Authority from Jan 2010 to May 2015 were analyzed to assess for the effect of previous volumes on future volumes. Parameters were selected using the auto-correlation (ACF) and partial auto-correlation functions (PACF) for a Seasonal Auto-regressive Integrated Moving Average (SARIMA) model. The Box-Jenkins statistic was assessed for model suitability. To assess for accuracy, a forecast of the model was evaluated with a year of volumes set aside for testing. Results: The EDs saw an average of 365.1 patients per day, with a minimum of 188 patients and a maximum of 479. The increasing trend in volumes consistent with the increasing number of ED presentations nation-wide was detrended using linear regression. There was a significant correlation in ACF with the previous day (ρ1 = 0.297). A seasonal, periodic trend was seen weekly. Significant correlations occurred annually (ρ365 = 0.279) and at 29 days (ρ29 = 0.339), consistent with the lunar cycle. A seasonal model was postulated incorporating an auto-regressive (AR) coefficient, and a moving average (MA) coefficient for the previous day’s volume. An AR and MA seasonal coefficient were each incorporated using the weekly period. When using the model on the test data, the model predicted 4 more patient presentations on average than the true value, with 90% of the values within 37 presentations of the true volume. The Box-Jenkins statistic was non-significant, indicating no problems with model specification. Conclusion: The volume of patients presenting to an ED system is correlated with that of the previous day. A weekly seasonal variation was confirmed. Auto-correlations also occur annually and possibly associated with the lunar cycle. Previous ED volumes may be useful in forecasting patient volumes. The time-series approach may discover further ways to predict ED volumes.