Introduction: Non-trauma centers (NTC) and community hospitals commonly deliver medical care during the “golden hour” of trauma, which has significant implications on the health outcomes of patients. The Niagara Health System (NHS) and its 3 community NTC hospitals provide trauma care to over 100 patients annually during this critical period. NTCs lack standardized resources commonly found in trauma centers. Checklists and bundles have been effective in streamlining process to ensure health care providers provide the right care, at the right time and address critical points during patient care. A trauma care bundle was designed and implemented in the NHS as a means to improve trauma care and patient outcomes. Methods: A quality improvement (QI) approach was used to design, implement and evaluate a trauma care bundle at one of the NHS’s community hospitals. These interventions were adapted and modified for community trauma care purposes. We piloted the trauma care bundle using rapid cycle improvements, known as Plan-Do-Study-Act (PDSA) cycles. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015-December 2015. A safety attitudes questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Results: Improvements to the bundle and its implementation from 4 PDSA cycles resulted in increased utilization. This continuous monitoring of the bundle and ongoing, conscious efforts to improve the intervention were used to spread and scale across all 3 sites of the NHS. 30% of patients received the trauma care bundle during phase 1 of the pilot from July 1- October 31, 2015. We are presently analyzing preliminary data to understand how the trauma care bundle impacts health outcomes and process and will present a comparative analysis between patient groups. Conclusion: Trauma care bundles may foster safer and more efficient patient care in community hospitals where the golden hour of trauma often occurs. This community trauma care bundle shows promising results for streamlining the care process to ensure patients receive appropriate care during the golden hour. Spread and scale of this bundle across other community hospitals will likely yield similar improvements in patient care.

Introduction: Rapid atrial fibrillation (AF) and flutter remains a common cause of emergency department (ED) visits. Canadian guidelines recommend a rhythm control strategy for patients presenting to ED within 48 hours of arrhythmia onset or who are anticoagulated. However, up to 70% of patients spontaneously convert within 24 hours, mitigating the need for urgent cardioversion. Moreover, education, risk stratification, appropriate anticoagulation, and follow-up may be challenging in the ED setting. Therefore, direct and rapid linkage to an AF clinic was proposed to address these gaps in care. Methods: A pilot evaluation of a “Short Duration AF Pathway” was performed at Kelowna General Hospital, B.C., from June 2014 to Feb 2015. This care pathway–consisting of a treatment algorithm, ED order set, and referral process–was applied to patients with AF≤48 hours or those who were anticoagulated. Patients received initial rate control medication in the ED and were referred for reassessment in a collaborative cardiologist/nurse practitioner AF clinic and seen within 24 hours. Data was collected prospectively; descriptive statistics are presented. Results: Twenty patients were enrolled during the pilot period. Mean age was 69 (SD=10) years, 6/20 (30%) female, mean CHADS65 score 1.35 (SD=1.1), with 15/20 (75%) CHADS65 ≥ 1. On presentation, 4/20 (20%) were taking anticoagulants and 12/20 (60%) had an AF history. All 20 patients were assessed in the AF clinic within 24 hours of referral. Upon assessment in the AF clinic, 10/20 (50%) had spontaneously converted to sinus rhythm and 5/20 (25%) were electrically cardioverted at the first AF clinic visit. The remaining 5/20 (25%) of patients were reclassified as AF of uncertain duration; one was admitted to hospital, the other four had delayed electrical cardioversion. All patients received education related to AF. No adverse events or readmissions to the ED were reported and 100% of patients with CHADS 65≥1 had received appropriate anticoagulation. Conclusion: A “Short Duration AF Pathway” is a viable alternate approach to immediate cardioversion within the ED. Potential advantages include avoiding unnecessary cardioversion, providing patient education, accessing timely specialty care, and initiating anticoagulation where appropriate.

Introduction: Cannabinoid hyperemesis syndrome (CHS) is a paradoxical side effect of cannabis use. Patients with CHS often present multiple times to the Emergency Department (ED) with cyclical nausea, vomiting and abdominal pain, and are discharged with various misdiagnoses. CHS studies to date are limited to case series. We examined the epidemiology of CHS cases presenting to two major urban Tertiary Care Centre EDs. Methods: Using explicit variables, trained abstractors, and standardized abstraction forms, we abstracted data for all adults (18-55 years) with a presenting complaint of vomiting, and/or a discharge diagnosis of vomiting and/or cyclical vomiting, during a 2-year period. Inter-rater agreement was measured using a kappa statistic. Results: We identified 494 cases: mean age 31 years; 36% male; only 19.4% of charts specifically reported cannabis use. Among the regular cannabis users (>3 times per week), 43% had repeat ED visits for similar complaints. Interestingly, of these patients, 92% had bloodwork done in the ED, 92% received IV fluids, 89% received anti-emetics, 27% received opiates, 19% underwent imaging, 8% were admitted to hospital, and 8% were referred to the Gastroentorology service. Inter-rater reliability for data abstraction was kappa = 1. Conclusion: This study suggests CHS may be an overlooked diagnosis for nausea and vomiting, a factor which can possibly contribute to unnecessary investigations and treatment in the ED. Additionally, this indicates a lack of screening for CHS on ED history, especially in quantifying cannabis use and eliciting associated symptoms of CHS.

Introduction: Diabetes mellitus affects over 2.7 million Canadians, with 90% being Type-2 diabetes (CDA 2010). Complications of diabetes are major causes for emergency department (ED) visits, adversely affecting patients’ health and costing the health system. Improving diabetes self-management can lead to avoidance of ED visits and revisits after discharge. Recent developments in mobile Health (mHealth), such as home health monitoring with sensors, social media, and text messaging, have shown promise in supporting patients in chronic disease self-management. This project tested the feasibility of these tools to support self-management for people with type-2 diabetes. Methods: Forty-three people with type-2 diabetes took part in a three month program that provided: health information via text messages, online access to curated resources and a facilitated discussion board, and access to wireless monitoring devices. Participants were outfitted with a wireless blood pressure monitor and weight scale, standard blood glucose monitor, and online access to their physiological data. Data collected included pre and post-self-reported health measures, tracking of physiological changes, website and discussion board use, cost survey, and interviews. Results: Participants reported significantly less health distress and an increase in diabetes empowerment. HbA1c levels decreased from an average of 7.41 to 6.77. Average weight and blood glucose also decreased over the study period. Interview and cost survey findings revealed most participants felt mDAWN provided good value; 78% expressed interest in continuing all or parts of the program. Interview findings revealed that participants developed self-management routines, and experienced increased self-awareness of, and ownership over, their health achievements. Conclusion: mHealth tools provided participants with their own physiologic information, connection with peers, and evidence informed advice. Participants highly valued this combination and improved their self-management and health outcomes. Equipping patients with similar tools for self-management post ED discharge holds great promise for decreasing revisits and improving health outcomes. This study has stimulated a clinical trial now underway to evaluate the effectiveness of home monitoring to facilitate the transition of patients between acute care and community settings.

Introduction: Adverse drug events are a leading cause of Emergency Department (ED) visits and unplanned admissions. Up to 50% are misdiagnosed in the ED and on hospital wards leading to treatment delays. Our main objective was to evaluate the effect of pharmacist-led medication review in high-risk ED patients on the number of days in-hospital. Our hypothesis was that early pharmacist-led medication review may reduce the number of days spent in-hospital. Methods: We evaluated a quality improvement program that was implemented in three British Columbian EDs. During a 12-month period, nurses identified consecutive patients at high-risk for adverse drug events using a clinical decision rule integrated into triage algorithms. Clinical pharmacist research assistants enrolled consecutive eligible high-risk patients, and systematically allocated them to medication review or control. In the intervention group, pharmacists collected best possible medication histories, reviewed medications for appropriateness and adverse drug events, and communicated review results to patients and physicians. In the control group, nurses collected best-possible medication histories, and physicians referred patients to the ED pharmacist as needed. Ongoing care was determined by physicians who were not blinded to group allocation, but were unaware of the evaluation. We assessed outcomes using administrative health databases. The primary outcome was the number of days spent in-hospital over 30 days. We used inverse propensity score weighted regression modeling to assess the relationship between medication review and health outcomes. The sample size was limited by the duration of the quality improvement program. Results: Among 10,807 patients 6,416 received medication review in the ED and 4,391 usual care. The groups were balanced in terms of baseline characteristics. The median number of hospital days was 0.48 days (95% confidence interval [CI] 0.00-0.96) less in the medication review group compared to usual care (p=0.058). The difference was 0.60 days (95% CI 0.06-1.17; p=0.03) less among patients under 80 years old. There was no effect on ED revisits, number of admissions and readmissions, or mortality. Conclusion: Medication review was associated with a trend in reduced hospital-bed utilization. While limited by lack of randomization, our evaluation suggests that ED pharmacists may impact subsequent resource utilization.

Introduction: In the Canadian province of Alberta, (pop. 4,227,879), the publicly-funded health care system uses the five level Canadian Triage and Acuity Scale (CTAS), to prioritize emergency department (ED) patients. Health system decision makers and policy makers currently use CTAS as an isolated metric to describe ED patient case-mix and to compare EDs. Methods: Using the National Ambulatory Care Reporting System dataset, we reviewed the distribution of patient CTAS scores and the proportion of inpatient admissions by CTAS level for the 16 highest volume Alberta hospital EDs during FY 2013/2014. Results: Collectively, the EDs received 1,027,976 patients, with 1%, 18%, 44%, 30% and 7% classified as CTAS 1-5, respectively. The proportions by CTAS level ranged from 0.2% to 2.8% in CTAS 1; 3.3% to 33.3% in CTAS 2; 29.1% to 54.1% in CTAS 3; 16.7% to 49.0% in CTAS 4; and 3.1% to 12.3% in CTAS 5. Admission proportions by CTAS level ranged from 43.9% to 75.2% in CTAS 1; 18.9% to 42.1% in CTAS 2; 5.4% to 24.7% in CTAS 3; 0.8% to 9.3% in CTAS 4; and 0.1% to 9.1% in CTAS 5. Conclusion: Inter-hospital differences in CTAS acuity distributions reflect triage variability and real differences in case-mix. Wide variation in admission proportions by CTAS level reflects differing admission thresholds between sites, but also suggest intra-level differences in patient severity, comorbidity and complexity. Triage levels cannot be used as an isolated metric to describe and compare ED case-mix. Further work is required to accurately characterize ED patient case-mix.

Introduction: Computed tomography (CT) scan utilization has increased dramatically over the past 25 years. This has sparked concern for potential overuse leading to unnecessary radiation exposure for patients and increased health care costs, without any improvement in health outcomes. In order to improve workflow through the Emergency Department (ED) at our institution, an existing pre-authorization policy during weekday business hours allows emergency physicians to order CT scans directly without the need for approval from a radiologist. This policy was recently expanded on September 28, 2015 to allow pre-authorized CT scan orders during weekday evening hours. The objective of our study is to evaluate the impact of increased availability of pre-authorized CT scan ordering on CT scan utilization and patient flow through the ED at two tertiary care hospitals in London, Ontario. Methods: This is a retrospective review comparing monthly CT scan utilization rates in the pre-implementation period from September 28, 2014 to February 28, 2015, to rates in the post-implementation period from September 28, 2015 to February 28, 2016. Length of stay parameters including time from physician initial assessment to CT scan order, completion, report and patient discharge will also be compared between the groups. Results: Results will be presented at CAEP 2016. No significant difference is expected in the monthly number of CT scans ordered per registered ED visits between the pre- and post-implementation groups. We also anticipate a significantly shorter average length of stay for patients receiving a CT scan in the post-implementation group. Conclusion: We expect there will be no significant increase in CT scan utilization with increased availability of pre-authorized CT scan ordering in our EDs. We also anticipated decreased patient length of stay leading to improved patient flow through the ED. Findings may offer support for organizations to safely implement or increase availability of pre-authorized CT scan orders to help improve patient flow and decrease costs in the ED.

Introduction: Patient handoffs have been identified as the primary cause of error affecting patient safety. The lack of standardization - and the often-avoidable errors that occur as a result - profoundly affect patient care and emergency department (ED) administration. Our study set out to evaluate emergency doctors’ awareness of these safety concerns, as well as their satisfaction with handoff practices currently used in their respective EDs. We also aimed to identify the potential barriers to the use of a standardized approach to patient transition of care. Methods: Guided by a modified Delphi method, a 29-question survey was developed by a panel of experts on patient transition of care. A printed version of the survey was distributed to ED doctors attending a local emergency medicine conference. An electronic version was subsequently distributed to all ED doctors registered as members of our provincial professional organizations. Results: We achieved a 68% response rate. Amongst the 309 participants, 51% (95%CI 44-56%) acknowledged that handoffs between emergency doctors are a frequent cause of error related to patient care. Frequent interruptions (77% (95%CI 72-82%)) and heavy workloads (73% (95%CI 68-79%)) were identified as the main factors negatively influencing the quality of handoffs. Despite 61% (95%CI 56-68%) satisfaction with the currently employed methods, 74% (95%CI 68-79%) of the respondents believe that handoffs would benefit from standardization and 83% (95%CI 79-88%) are open to changing their current practices. In addition, 53% (95%CI 48-60%) believe that the tools used for transition of care can be improved. Apprehension regarding the increase of handoff burden (86% (95%CI 81-90%)) was identified as the primary barrier to the implementation of a standardized handoff protocol. Conclusion: Doctors are generally satisfied with current handoff practices used in the ED. Nevertheless, their awareness of the possible risks associated with transition of care may be driving their openness to adapting their practice, potentially towards a more standardized approach given the conceivable benefits to patient safety. In light of these results, we aim to develop a comprehensive, standardized handoff protocol, and to evaluate its applicability in the ED with a prospective study.

Introduction: The recently published ProMISe, ARISE and ProCESS trials demonstrated that protocol-based resuscitation (EGDT) of ER patients in whom septic shock was diagnosed did not improve outcome when compared to usual care. The objective of this project was to survey McMaster emergency physicians in areas including sepsis definition, clinical recognition in adults, self-rated skills assessment, attitudes towards skills augmentation and compare results to the cohort surveyed 11 years ago, close to the introduction of EGDT. Methods: Full time faculty at McMaster’s Department of Emergency Medicine and ER residents were surveyed anonymously using an electronic survey. The questions covered demographics and training data, identification of septic patients, sepsis intervention and attitudes towards skills augmentation. Results: A total of 18 physicians responded to the electronic survey to date. All respondents were able to correctly input definitions for SIRS, sepsis, severe sepsis and septic shock. The majority of respondents felt the best strategy to identify potentially septic adults involved monitoring abnormal vital signs (67%) with some stating serum lactate assessment (33%). Of the 11 possible interventions options provided to care for septic patients, respondents appeared more comfortable with placement of lines, giving vasopressors and appropriate use of fluids for resuscitation. This was compared to more specialized interventions like initiating IV steroids in vasopressor dependant shock despite adequate fluid loading. 22% of respondents believed that patients without respiratory compromise with clinically severe sepsis should be intubated which was found to be 48% in the previous cohort surveyed 11 years ago. 78% believed patients in septic shock without respiratory comprise should be intubated, reassuringly similar to the previous survey result of 87%. Conclusion: Emergency physicians at our Canadian institution are comfortable with the skill set required to care for patients with sepsis. Respondents surveyed to date were all comfortable with important resuscitative measures including accurate identification, placement of lines and appropriate fluid administration and were receptive to additional training. Our study emphasizes that our physicians have the skill set to identify and provide care for sepsis using their clinical judgment in cases that may not require protocolized based care.

Introduction: Emergency medical services (EMS) have the opportunity to treat allergic reactions anaphylactic reactions rapidly. However, the rate of recognition and treatment is unknown. Methods: This was a retrospective cohort study conducted at two urban emergency departments from 2007 to 2012 including adult patients with allergy and anaphylaxis, both of which were predefined by explicit criteria. The patients of interest were those attended by EMS and transported to hospital. The primary outcome was the proportion of patients who met anaphylaxis criteria in the prehospital setting, but who did not have epinephrine administered. The secondary outcome was the proportion of patients who did not meet anaphylaxis criteria, yet had epinephrine administered. Results: Of 2819 overall patients, 491 (17.4%) arrived by EMS. The median age was 38 (IQR 27 to 49) and 60.9% were female. For the 151 (30.8%) patients with anaphylaxis, 55 received ephinephrine, (36.4%, 95% CI 27.4 to 47.4%). For the 340 (69.2%) patients without anaphylaxis, 28 received ephinephrine (8.2%, 95% CI 5.5 to 11.9%). Conclusion: For patients with anaphylaxis and allergic reactions who are managed by EMS, there may be a mismatch between illness severity and treatment.

Introduction: Standardized tools for disseminating knowledge summaries of low value or unnecessary care (e.g., testing, procedures and treatments) are limited, but needed to equip clinicians for discussions with patients about care decisions. The objective of this study is to assess the acceptability of a tool developed by our emergency department (ED) team to communicate the evidence supporting the Choosing Wisely Canada© (CWC) and other similar recommendations. Methods: A consensus process was used by team members to develop a tool that highlights three areas: Facts, Gaps, and Acts. The Facts portion highlights the current state of knowledge and illustrates the strength of the evidence supporting guideline recommendations. The Gaps section identifies variation in current clinical practice. The Acts section includes larger CWC goals, as well as specific next steps for a demonstration project. Each section contains one key message for clinicians, ensuring the tool is easy to use. Results: A test case has been developed for avoiding chest radiographs in patients with an exacerbation of documented asthma. The Facts section reviewed current guidelines for asthma care. The Gaps section collated evidence from a systematic review and primary research. The Acts section recapitulates the CWC recommendations. In order to assess acceptability feedback cycle will be completed using surveys of 50 patients and 50 clinicians. Conclusion: While generating the Facts, Gaps, and Acts tool for a CWC recommendation represents a translational activity, evidence of effectiveness is needed prior to widespread implementation. We report the rational and development of a novel tool to engage clinicians and patients in conversations about unnecessary care in the ED.

Introduction: The use of free open access medicine, particularly open educational resources (OERs), by medical educators and learners continues to increase. As OERs, especially blogs and podcasts, rise in popularity, their ease of dissemination raises concerns about their quality. While critical appraisal of primary research and journal articles is formally taught, no training exists for the assessment of OERs. Thus, the ability of educators and learners to effectively assess the quality of OERs using gestalt alone has been questioned. Our goal is to determine whether gestalt is sufficient for emergency medicine learners (EM) and physicians to consistently rate and reliably recommend OERs to their colleagues. We hypothesized that EM physicians and learners would differ substantively in their assessment of the same resources. Methods: Participants included 31 EM learners and 23 EM attending physicians from Canada and the U.S. A modified Dillman technique was used to administer 4 survey blocks of 10 blog posts per subject between April and August, 2015. Participants were asked whether they would recommend each OER to 1) a learner or 2) an attending physician. The ratings reliability was assessed using single measures intraclass correlations and their correlations amongst the groups were assessed using Spearman’s rho. Family-wise adjustments were made for multiple comparisons using the Bonferroni technique. Results: Learners demonstrated poor reliability when recommending resources for other learners (ICC= 0.21, 95% CI 0.13-0.39) and attending physicians (ICC = 0.16, 95% CI=0.09-0.30). Similarly, attendings had poor reliability when recommending resources for learners (ICC= 0.27, 95% CI 0.18-0.41) and other attendings (ICC=0.22, 95% CI 0.14-0.35). Learners and attendings demonstrated moderate consistency between them when recommending resources for learners (rs=0.494, p<.01) and attendings (rs=0.491, p<.01). Conclusion: Using a gestalt-based rating system is neither reliable nor consistent when recommending OERs to learners and attending physicians. Learners’ gestalt ratings for recommending resources for other learners and attendings were especially unreliable. Our findings suggests the need for structured rating systems to rate OERs.

Introduction: Handovers in the ED are a high risk area for breakdown in team communication, discontinuity of patients’ clinical course, and potential medical errors. This is especially true for morning handovers at our center, when one single overnight MD working with limited resources hands over the entire ED to an oncoming day team of MDs and allied health professionals. We describe a quality improvement (QI) project to implement an inter-professional team approach during handovers. Methods: This prospective QI project took place at an academic tertiary care centre with >160,000 ED visits/yr. An expert working group identified key components of the ideal morning handover, and developed an intervention consisting of standardizing the “location”, “participants”, and “time” components of our handover processes. A research assistant directly observed all 8am handovers for 2 weeks pre- and 2 weeks post-intervention. Outcomes include participant attendance; # of beside RN issues proactively brought forward; frequency of new allied health consults and/or involvement triggered; # of physician interruptions; and time metrics. We report descriptive statistics. Results: During the study period a total of 308 individual patient handovers were observed [Pre:162, Post:146]. Average duration of total handover each morning decreased from 24.9min to 16.3min (p=0.051). Frequency of attendance at handovers increased for various allied health professionals, including care facilitators [Pre:35.7%; Post:91.7%, p=0.005], social workers [Pre:7.1%; Post:66.7%, p=0.003], geriatrics EM (GEM) RNs [Pre:64.3%; Post:83.3%, p=0.391], pharmacists [Pre:0.0%; Post:58.3%, p=0.001], and physiotherapists [Pre:0.0%; Post:58.3%, p=0.001]. Number of specific beside RN issues proactively brought forward increased [Pre:0; Post:4, p=0.049], while the number of physician interruptions during handover decreased [Pre:20; Post:0, p<0.0001]. Frequency of new allied health consults and/or involvement triggered as a result of handover participation increased from 6.8% to 13.7% (p=0.057). Conclusion: Implementation of a standardized team approach to morning handovers in the ED led to significant improvements in inter-professional contributions to patient care plans and overall efficiency. Future planned phases will build on this QI initiative by standardizing specific content of ED handovers.

Introduction: Unintentional overdose is the leading cause of injurious death among Americans aged 25-64 years. A similar epidemic is underway in Canada. Community-based opioid overdose education and naloxone distribution (OOEND) programs distribute take-home naloxone kits to people at risk of overdose in several cities across Canada. Due to the high rate of drug-related visits, recurrent opioid prescribing, and routine encounters with opioid overdose, Emergency Departments (ED) may represent an under-utilized setting to deliver naloxone to people at risk of opioid overdose or likely to witness overdose. The goal of this study was to identify Canadian emergency physician attitudes and perceived barriers to the implementation of take-home naloxone programs. Methods: This was an anonymous web-based survey of physician and trainee members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals, per the modified Dillman method. Respondent demographics were collected and Likert scales used to assess attitudes and barriers to the prescription of naloxone from the ED. Results: A total of 347/1658 CAEP members responded (20.9%). Of the respondents, 62.1% were male and residents made up 15.6%. The majority (48.2%) worked in Ontario and 55.7% worked in an urban tertiary centre. Overall attitudes to OOEND were strongly positive: 86.6% of respondents identified a willingness to prescribe naloxone from the ED. Perceived barriers included allied health support for patient education (56.4%), access to follow-up (40.3%), and inadequate time in the clinical encounter (37.7%). In addition to people at risk of overdose, 78% of respondents identified that friends and family members may benefit from OOEND programs. Conclusion: Canadian emergency physicians are willing to prescribe take-home naloxone to at-risk patients, but better systems and tools are required to facilitate opioid overdose education and naloxone distribution implementation. This data will inform the development of these programs, with emphasis on allied health support, training and education.

Introduction: Mild Cognitive Impairment (MCI) remains frequently undiagnosed and Emergency Department (ED) guidelines suggest screening for CI. The Bergman-Paris Question (BPQ) which is currently used in memory clinics, is a one-question screening test administered to the patient’s relative; a negative answer suggests presence of CI. We sought to validate if the BPQ would be associated with MCI and functional status in ED elders. Methods: A planned sub-study of the prospective MIDI-INDEED study on ED-induced delirium, which included patients from 4 Canadian EDs was realized. Inclusion criteria were: patients ≥65 y.o., with and ED stay ≥8 hours, admitted to the hospital, non-delirious at the end of the first 8 hours and independent or semi-independent. Eligible patients were assessed in ED and at 60 days after ED visit using validated screening tests: the Telephone Interview for Cognitive Status-modified (TICS-m) for CI and the Older Americans Resources and Services scale (OARS) for functional status. The BPQ was asked at any time depending on the availability of a relative. Patients with a TICS-m score <31 are considered to have MCI. Data from patients with incident delirium, and those with documented dementia was individually analyzed. Univariate and multivariate analyses were used to ascertain outcomes. Results: 167 patients had a BPQ response, 126 (75.5%) were negative, and 41 positive (24.5%). For MCI, 40 (32.8%) patients of the negative group have a TICS-m below 31 comparatively to 6 (14.3%) for the positive group (p=0.2). The BPQ was significantly associated with functional status. The mean OARS scores were 25.1 (3.9) in the negative group and 27.1 (1.3) in the positive group. This difference was maintained at 60 days. The number of delirium in the negative group was 24 (18%) vs 2 (5%) in the positive group (p=0.04). Conclusion: BPQ could provide detection of MCI but further validation in a larger population is needed. BPQ was interestingly associated with ED-induced delirium and dementia. Detection of functional status and frailty shows good results. More research is needed to evaluate the usefulness of the BPQ “single” question for geriatric screening by ED professionals.

Introduction: Rib fractures represent a frequent condition associated with Minor Thoracic Injury (MTI). Since the last decade, ultrasound have become an important part of emergency physician’s (EP) daily practice, and its applications have become numerous. The main objective of this study was to evaluate the feasibility of Emergency Department Targeted Ultrasound (EDTU) for rib fracture diagnosis in patients with MTI. Secondary objectives were to 1) evaluate patients’ pain during the EDTU procedure, 2) assess clinicians’ degree of certitude over rib fracture diagnosis made by EDTU, 3) identify the limitations of the use of EDTU technique, and 4) compare the diagnosis obtained with EDTU to radiography results. Methods: Adult patients who presented with clinical suspicion of rib fractures after MTI were included. All patients underwent EDTU performed by emergency physicians (EP) prior to a rib view X-ray. Visual Analogue Scale (VAS) ranging from 0 to 100 was used to ascertain feasibility, patients’ pain and clinicians’ degree of certitude. Feasibility was defined as a score of more than 50 on the VAS. We also documented the radiologists’ interpretation of rib view X-ray. Radiologists were blinded to the EDTU results. Results: Ninety-six patients were included. A majority (65%) of EP concluded that the EDTU technique to diagnose rib fracture was feasible (VAS score > 50). Median score for feasibility was 63. Median score was 31 (Interquartile range (IQR) 5-57) for patients’ pain related to the EDTU examination and 72 (IQR 32-92) for the degree of certitude over the diagnosis made by EDTU. The main limiting factor of the EDTU technique was pain during patient examination (15%). Conclusion: EDTU examination appears to be a feasible technique for rib fractures diagnosis in the ED.

Introduction: Six Canadian provinces recently made bicycle helmet mandatory and subsequent data concerning hospitalization rates after head injuries in cyclists were controversial. Furthermore, there remains an important proportion of participants who don’t wear a helmet in sporting activity. We thus wanted to estimate the impact of helmet use in sport injuries on the risk of hospitalization. Methods: Study participants were patients of all age presenting at the emergency department of the Hôpital de l’Enfant-Jésus du CHU de Québec for a trauma that occurred in a sport in which it’s possible to wear a helmet. Data were collected from information provided by the patient and from the Canadian Hospitals Injury Reporting and Prevention Program’ (CHIRPP) database. Descriptive and multivariate analyses have been carried out using these data. We performed binomial logistic regression analyzes to estimate the risk adjusted for potentially confounding variables: age, sex and number of injuries. Results: Most patients included in the study (n=169) were males (69.8%) aged between 10 and 30 years (50.3%). Sports most frequently involved in trauma were cycling (31.4%), downhill skiing (18.3%), snowboarding (14.8%), hockey (11.8%), and skateboarding (5.9%). Overall, 70.4% of patients were wearing a helmet at the time of injury. Helmet use in sports was associated with a reduction of 52% of the risk of hospitalization (RR: 0.48 [CI: 95%: 0.25-0.93]) after a trauma. In addition, patients not wearing a helmet had higher proportions of intracranial hemorrhage (10% vs. 1.7%) and skull fracture (8% vs 2.5%). Conclusion: Results suggest that helmet use decreases the risk of hospitalization for trauma sustained in sports in which it’s possible to wear a helmet.

Introduction: Between 1980 and 2008, survival rates following an out-of-hospital cardiac arrest (OHCA) have remained unchanged, averaging 7.6%. Despite the use of new and emerging technologies, new medications, and automated external defibrillators, survival remains low. Recently, a new focus in cardiopulmonary resuscitation (CPR) has shown dramatic improvements in survival post OHCA. This new model, called pit-crew CPR, focuses on minimizing interruptions in chest compressions and has each team member playing a specific role in the resuscitation, akin to the pit-crew of a car race. Certain districts in the United States and Canada have adopted the pit-crew, or a similar, high quality, maximum time-on-chest CPR model, with much success. We aim to determine whether the pit-crew model of CPR improves survival following OHCA in Saskatoon, SK. Methods: In Saskatoon, EMS and Fire crews respond to OHCAs and have been exclusively using the pit-crew model of CPR since Jan 1st, 2015. This study is a before and after retrospective chart analysis, comparing two groups - pre and post implementation of the pit-crew CPR model. The primary outcome is survival to hospital discharge post OHCA. Secondary outcomes include survival to admission and any return of spontaneous circulation (as per the Utstein definition). The inclusion criteria are patients >18 years old with a witnessed OHCA of presumed cardiac origin who receive CPR by EMS/Fire within the Saskatoon Ambulance service (MD Ambulance) catchment area. Patients were excluded if the OHCA was unwitnessed, or if there was a presumed non-cardiac cause for the arrest, e.g. trauma. Results: In the pre-pit-crew model cohort, between Jan 1st, 2011 and Sept 31st, 2014, 455 OHCAs were analyzed. In this cohort 10.5% survived to discharge, 31.9% survived to admission and ROSC was achieved in 39% of cases. The percentage of patients with initial rhythms of VF/VT, asystole or PEA were 28.5% (26%), 41.5% (1%) and 23.6% (10%) respectively, with survival to discharge shown in parentheses. The post-pit-crew cohort is still in the data collection phase. Conclusion: Our pre-pit crew cohort data has been collected and analyzed. With ongoing data acquisition for the post-pit crew cohort, we hope to have the full data set complete by the end of 2018. It will be at that time when we are able to determine whether the pit-crew model of CPR improves survival to discharge following OHCA in Saskatoon.

Introduction: The incidence of delirium following hip fracture is near 60%. The use of regional anesthesia (RA) with ultrasound (U/S) guidance has suggested a decrease in delirium incidence. In this pilot study, we propose to include the use of femoral block with U/S guidance in the management of the elderly population with hip fracture in the emergency department (ED) to lower the risk of delirium. Methods: This paired control case study was conducted from December 2013 to April 2015, and includes patients seen by emergency doctors from the ED of Hospital Enfant Jesus in Quebec City. Patients of the intervention and control groups were paired by age. Inclusion Criteria: Patients with(1) a hip fracture; (2) admitted to the hospital after their ED management; (3) and surgically repaired. Exclusion Criteria: Patients (1) with delirium upon arrival or a known mental/cognitive status (dementia, unconsciousness or severely ill status) (2) less than 60 years old (3) not able to speak English or French. Intervention group: Patients with hip fracture who received femoral blocks by the five emergency doctors who were trained and performed with U/S guidance. Control group: Patients with hip fracture who received standard pain control care by emergency doctors and who did not receive a femoral block. Analysis: Incidence of delirium and blocks performed by EM doctors were tallied. A comparison of absolute pain reduction at 30 minutes was also done. Odd ratios were derived and adjusted for age, sex, total opiates dose, delay before surgery and morbidity scores. Results: A total of 29 femoral blocks were performed through the analysis period. Groups were similar for age, sex and APACHE II and CHARLSON scores. A 30 minutes absolute pain reduction of 3/10 was noted. Two thirds of the blocks were performed by two ED doctors. Need for rescue medication was needed for 7% of patients for pain control at 30 minutes. Adjusted odd ratios for age, sex, morbidity scores, total opiate doses and delay before surgery revealed no decrease in delirium. Conclusion: Ten out of 26 patients hospitalized for hip fracture who received a femoral block under U/S guidance from the ED doctors were diagnosed with delirium. A Canadian prospective study «EDURAPID» is underway to demonstrate more the impact of R/A under U/S guidance on the incidence de delirium in this population.

Background: Intravenous (IV) and Intranasal (IN) route for analgesic administration cannot always be used to provide adequate pain management in pre-hospital setting. Objective: In a rural and suburban pre-hospital setting, studying the feasibility, safety and effectiveness of the subcutaneous (SC) route for fentanyl administration by Basic Life Service-Emergency Medical Technician (BLS-EMT) for pain management, with the support of an online medical control (OLMC) center. Methods: Retrospective study of patients who received subcutaneous fentanyl and were transported by BLS-EMT to an emergency department (ED). Safety and feasibility were characterized by collecting vital signs, Ramsey sedation scores and adverse events following fentanyl administration, and effectiveness was evaluated by changes in pain scores. Parametric and non-parametric tests were used for statistical analyses comparing age groups (<70 & ≥70 years old) regarding transport time. Results: Pain scores ≥7 were found in 288 patients (14-93 years old) who were eligible for analgesia. 249 (86.5%) of the 284 (98.6%) who received subcutaneous fentanyl were included for analysis. At baseline, no difference (p>0.05) in pain scores pre-fentanyl between groups even if patients<70 years old received a significant higher dose of fentanyl than those ≥70 years old (1.4±0.3 v/s 0.8±0.2mcg/kg, p<0.05). Post-administration pain score decreased significantly while proportion of patients achieving a pain relief increased significantly (p<0.05) regarding transport time (15, 30 or 45min) to ED. Adverse events were present in 1.6% of the patients [hypotension (n=2; 0.8%), nausea (n=1; 0.4%), and Ramsey score>3 (n=1; 0.4%)]. Conclusion: Under the supervision of an OLMC center, subcutaneous fentanyl administration by BLS-EMT for pain management seems to be a feasible approach, with a safe and effective route without major adverse event in pre-hospital setting. Pain relief increased with longer transport time. Further studies are needed to determine the benefits of SC route when compared to other administration routes in EMS.